A Single Center Experience of In Situ Needle Fenestration of Supra-aortic Branches During Thoracic Endovascular Aortic Repair

Ye, Xiang; Qiu, Chenyang; He, Yangyan; Li, Donglin; Shang, Tao; Wu, Ziheng; Zhang, Hongkun

doi:10.1016/j.avsg.2019.03.016

Cited by 27 publications

(24 citation statements)

References 27 publications

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“…[5][6][7] Since McWilliams et al 11 reported the first in situ fenestration to preserve the LSA in 2004, there have been many reports and reviews confirming the safety and feasibility of this technique using a variety of puncture methods. [5][6][7][12][13][14][15][16] However, when performing total endovascular arch debranching using the in situ fenestration technique, blood flow to the supra-aortic branches must be rerouted to ensure blood supply to the brain. Current methods include establishing extracorporeal circulation, 17 prosthetic bypass, 18 or a temporary shunt.…”

Section: Discussionmentioning

confidence: 99%

“…9 However, when all 3 supra-aortic branches are targeted for in situ fenestrations, the aortic stent-graft will temporarily cover all branches during deployment, so temporary blood diversion is required to ensure blood supply to the brain. 10 At present, extracorporeal circulation or external flow methods are mainly employed, 6,7,9 but endovascular shunting has also been used. 10 Recently, our department has adopted an improved method of combining internal bypass with external flow rerouting to establish temporary brain perfusion during in situ triple fenestrations in the aortic arch.…”

Section: Introductionmentioning

confidence: 99%

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A Novel Internal and External Bypass Method to Safeguard Cerebral Blood Flow During Aortic Arch Endovascular Repair Requiring Triple In Situ Fenestrations

et al. 2019

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Purpose: To report a novel internal and external blood bypass method for cerebral protection during in situ triple-fenestrated stent-graft repair in the aortic arch. Technique: A method was devised to combine internal and external blood bypass circuits to preserve cerebral blood flow when all 3 supra-aortic branches are covered by the stent-graft. Long 14-F to 18-F introducers are placed retrogradely into the right and left common carotid arteries (CCAs). Smaller sheaths are placed antegradely into the internal carotid arteries (ICAs) bilaterally and into the right CCA introducer, which has had an aperture cut into it for flow to pass into the smaller sheath. The right CCA introducer is positioned in the ascending aorta to supply the innominate artery; the smaller sheath in the right CCA introducer is positioned at the aperture. The small sheath in the right CCA is connected to the left ICA sheath, and the left CCA fenestration is made and stented. The left ICA sheath is connected to the right ICA sheath, and the right CCA introducer is pulled back to the origin of the innominate artery and the smaller sheath removed. The fenestrations for the innominate and left subclavian arteries are opened sequentially. In 8 patients, complete bypass to maintain brain perfusion was performed for an average 17.6±6.9 minutes; intraoperative transcranial Doppler monitoring during flow bypass showed no notable decline in intracranial blood flow velocity. Two patients suffered stroke; one recovered completely. Conclusion: A cerebral protection strategy that integrates internal and external blood flow bypass techniques to maintain adequate brain blood flow is simple and feasible for in situ triple-fenestration aortic arch stent-graft repairs. However, neurological complications were not avoided with this method; thus, further research and development are required.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

A Novel Internal and External Bypass Method to Safeguard Cerebral Blood Flow During Aortic Arch Endovascular Repair Requiring Triple In Situ Fenestrations

et al. 2019

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“…Recent studies mainly focused on ISF using a laser or radiofrequency device 8–11 ; ISNF has been less frequently reported, with <200 cases recorded in the English-language literature up to now. 12,13…”

Section: Introductionmentioning

confidence: 99%

Midterm Results of Retrograde In Situ Needle Fenestration During Thoracic Endovascular Aortic Repair of Aortic Arch Pathologies

et al. 2020

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Purpose: To evaluate the safety and feasibility of the in situ needle fenestration (ISNF) technique for reconstruction of the left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR) of complicated aortic arch pathologies. Materials and Methods: A retrospective review was conducted from January 2014 to December 2019 of 50 patients (mean age 60.2±11.1; 45 men) who underwent ISNF to revascularize the LSA during TEVAR. Twenty-one of the patients also required revascularization of the left common carotid artery (LCCA; n=19) and innominate artery (IA; n=2) using physician-modified in vitro fenestration. Overall, 73 supra-aortic branches were targeted for revascularization. Results: ISNF was successful in 48 patients (96%); one LSA could not be stented and a tortuous LSA prevented the needle from fenestrating the graft. No perioperative major adverse event occurred. There were no type I and 4 type III endoleaks (8%), 3 of which occurred among the first 20 cases. Types II and IV endoleaks were found in 3 (6%) and 6 (12%) cases, respectively; all disappeared during a median follow-up of 15 months (range 3–66). One death (2%) occurred within 12 months due to cerebral hemorrhage. Two patients (4%) required open reinterventions at 6 and 62 months. Conclusion: ISNF for revascularization of the LSA during TEVAR seems to be feasible with acceptable midterm outcomes. The learning curve and evolving patient selection criteria affected technical success, complications, and the need for reinterventions. Long-term durability requires further evaluation.

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“…Involvement of supra‐aortic branches is a major obstacle to TEVAR. Several techniques have been developed to tackle this problem, including debranching, inserting chimney stents, placing branched endografts, and in situ fenestration (ISF) 1,2 . However, debranching techniques are more invasive, the chimney technique increases the risk of endoleak, and branched endografts require custom manufacture, making them more costly and necessitating a long wait time.…”

mentioning

confidence: 99%

“…It usually involves penetrating the aortic stent graft with a needle, laser, or radiofrequency 1 . Most ISF techniques have used covered stents, with overall good success rates and acceptable short‐term outcomes 2 . However, the use of bare‐metal stents (BMS) inserted in retrograde fashion has not been addressed thoroughly.…”

mentioning

confidence: 99%

Thoracic aortic disease: Can we safely cover the branches?

Shatila

Krajcer

2020

Cathet Cardio Intervent

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E d i t o r i a l C o m m e n tExpert Article Analysis for: Mid-term results of in situ fenestration stented with balloon-expandable bare metal stents during thoracic endovascular aortic repair Key Points• Thoracic aortic disease has usually been treated with surgery.• Thoracic endovascular aortic repair is challenging if supra-aortic vessels are involved.• In situ fenestration of the main graft from a retrograde approach while using bare-metal stents as bridge stents appears to be a safe and practical technique.

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A Single Center Experience of In Situ Needle Fenestration of Supra-aortic Branches During Thoracic Endovascular Aortic Repair

Cited by 27 publications

References 27 publications

A Novel Internal and External Bypass Method to Safeguard Cerebral Blood Flow During Aortic Arch Endovascular Repair Requiring Triple In Situ Fenestrations

A Novel Internal and External Bypass Method to Safeguard Cerebral Blood Flow During Aortic Arch Endovascular Repair Requiring Triple In Situ Fenestrations

Midterm Results of Retrograde In Situ Needle Fenestration During Thoracic Endovascular Aortic Repair of Aortic Arch Pathologies

Thoracic aortic disease: Can we safely cover the branches?

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