Endovascular treatment for aortic arch pathologies: chimney, on-the-table fenestration, and in-situ fenestration techniques

Abstract

Background: Revascularization of the supra-aortic major branches in thoracic endovascular aortic repair (TEVAR) is challenging owing to the complex anatomic configuration of aortic arch pathologies. This study aims to evaluate the feasibility, effectiveness, and safety of three major techniques-chimney, fenestrated, and in-situ fenestration-for patients with aortic arch pathologies. Methods: A retrospective analysis was performed involving 234 patients with aortic arch lesions, who underwent TEVAR with adaptations in technique (chimney, fenestrated, or in-situ fenestration) between January 2016 and December 2017. Results: One hundred and twenty-six patients underwent the chimney technique (98 single chimneys, 24 double chimneys, and four triple chimneys); one hundred and two patients (102/234) were treated with on-the-table fenestration technique (92 single fenestrations, nine double fenestrations, and one double fenestration plus innominate artery chimney); and the remaining six patients underwent in-situ needle fenestration technique. Overall, indications included aortic dissections (99/234), aortic arch aneurysms (60/234), penetrating aortic ulcers (72/234), and re-interventions (3/234). The technical success rates were 99.6%. There were five cases of early all-cause mortality. The patency rates of overall branches were 99.6%.There were 15 cases with type Ia endoleak-14 in the chimney group (11.1%) and one in the on-the-table fenestration group (1%). Five patients underwent re-interventions. The median follow-up time for all patients was 28 (range, 16-41) months. Conclusions: Our experience suggests that chimney, on-the-table fenestration, and in-situ needle fenestration techniques are feasible, effective, and safe treatment options for aortic arch pathologies with encouraging mid-term results. Long-term durability concerns require further evaluation.

Optimal In Situ Fenestration Technique With Laser Perforation and Balloon Dilation for Aortic Stent-Grafts

“…There are various methods for retrograde fenestration, which include needle, 19,20 radiofrequency, 7,21 or laser. 22 Currently, there is limited evidence to support the choice of one technique over another. Studies from Lin et al 23 suggest a theoretical advantage of using an energy-based method (radiofrequency or laser) because the fusion of fibers created by this device may prevent some of the fraying observed after balloon dilation.…”

Surgeon-modified fenestrated stent graft deployment in type B aortic dissection

“…Alternative endovascular techniques have been documented for LSA protection. [ 2 , 3 ] Regarding the chimney technique of deploying parallel grafts to the aortic stent graft poses the risk of perigraft endoleaks. [ 4 ] In situ needle fenestration is a potential revascularization technique; however, it is currently not available in Turkey and has a remarkable cost.…”

The best option for complicated type B dissection with arch involved

“…Fenestration technique (f-TEVAR), including in vitro (namely, physician-made, physician-modified, or on-the-table) and in situ , [ 7 , 8 ] is another feasible endovascular technique. Compared with ch-TEVAR, there is no risk of gutter endoleak.…”

“…However, there is no evidence of a higher rate of mortality or complication caused by increased complexity. [ 7 ] Single-vessel laser fenestration is reported to suffer from endoleak in 2.5%, stroke in 2.5%, and retrograde dissection in 1.7%. More complications occur in multi-vessel in situ fenestration.…”