In Situ Laser Fenestration for Revascularization of the Left Subclavian Artery in Diseases of the Aortic Arch

Summary

This article presents a detailed protocol for in situ laser fenestration for revascularization of the left subclavian artery during thoracic endovascular aortic repair, along with an analysis of midterm clinical outcomes. The experience is intended to provide fellow practitioners with insights into its clinical application.

Abstract

Thoracic endovascular aortic repair (TEVAR) has become a widely established treatment for aortic arch pathologies in recent years. However, lesions near or involving the origin of the left subclavian artery (LSA) often present challenges in securing an adequate proximal landing zone. Various technical approaches, including parallel graft techniques, fenestration, chimney grafts, branched devices, and others, have been developed to optimize the proximal landing zone while preserving LSA perfusion. Among these approaches, in situ laser fenestration (ISLF) of the LSA has emerged as a highly versatile and safe technique, demonstrating high success rates. This article provides a comprehensive overview of perioperative management and critical procedural steps for performing ISLF of the LSA, and presents clinical outcomes from a consecutive case series with a technical success rate of 94.5%. The objective is to offer vascular surgeons and interventional radiologists detailed insights to support the safe and effective application of this advanced technique.

Introduction

The treatment of thoracic aortic diseases has rapidly evolved in recent years. Thoracic endovascular aortic repair (TEVAR) is now widely used to manage thoracic aortic aneurysm (TAA), thoracic aortic dissection (TAD), penetrating aortic ulcer (PAU), intramural hematoma (IMH), and thoracic aortic injury (TAI)¹. TEVAR has even become the preferred approach for the elective treatment of descending TAAs and other thoracic aortic pathologies². To secure an adequate proximal landing zone during TEVAR, it is often necessary to cover the left subclavian artery (LSA), a step that may lead to complications³....

Protocol

This protocol was approved by the Ethics Committee and Institutional Review Board of the First Affiliated Hospital of Zhengzhou University. Written informed consent for in situ laser fenestration (ISLF) is obtained from all patients undergoing thoracic endovascular aortic repair (TEVAR) at this institution, where the procedure is routinely performed. The inclusion criteria were as follows: (1) Patients with aortic arch pathologies undergoing TEVAR; (2) Patients with a proximal landing zone less than 15 mm adjacent to the aortic arch lesion; (3) Patients who underwent left subclavian artery (LSA) revascularization via ISLF and provided written informed consent....

Results

This study retrospectively analyzed follow-up data from 127 patients who underwent thoracic endovascular aortic repair (TEVAR) with in situ laser fenestration (ISLF) for left subclavian artery (LSA) revascularization at this institution between July 2019 and April 2022. The median follow-up duration was 43 months (range: 28 to 65 months). The mean patient age was 55.1 ± 12.4 years, with 107 males (84.3%) and 20 females (15.7%) (Table 1).

The primary diagnoses included.......

Discussion

ISLF is becoming more prevalent in the revascularization of branch vessels during TEVAR. ISLF for revascularization of branch vessels during TEVAR is safe and does not require much time for pre-operative measurements and stent design²⁰. The intraoperative fenestration process also does not require much time and is suitable for patients with acute or unstable conditions^21,22. Relatively few maneuvers are performed within the aortic lumen, w.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Angiographic Catheter	Merit Medical System	7602-20M	Catheter for angiography
Angiographic Catheter	Cordis Corporation	451-503H5	Catheter for angiography
Aortic Covered Stent System	Lifetech Scientific	XJZDZ232100	Stent graft system
basixCOMPAK	Merit Medical System	IN4130	A digital inflation device for balloons
Flexor Check-Flo Introducer	COOK Incorporated	KCFW-7.0-35-55-RB-HFANL1-HC	Used to introduce interventional devices
Laser Fiber Transmission System	Wuhan Gigaa Optronics Technology Co	GA-400-2	Deliver the laser
Perclose ProGlide	Abbott Vascular	12673	Vascular suture system
PTA Dilatation Catheter	ev3	AB35W03060135	Dilate blood vessels or stents
PTA Dilatation Catheter	Boston Scientific Corporation	H74939171100410	Dilate blood vessels or stents
Short Sheath Introducer	Merit Medical System	PSI-8F-11-035-18G	Sheath Introducer
Short Sheath Introducer	Merit Medical System	PSI-5F-11-035-18G	Sheath Introducer
Steerable Introducer	Lifetech Scientific	SVA7F-700	Establish access for device introduction
vascular stent graft	Angiomed GmbH & Co.MedizintechnikKG	FVL1004010*40	Stent graft
Wire	TERUMO	RF*GA35183M	Soft and ultra-smooth guidewire
Wire	TERUMO	RF*GA35263M	Soft and ultra-smooth guidewire
Wire	William COOK Europe ApS	TSCMG-35-300-LESDC	Guidewire