A. Natour1, A. Shepard1, T. Nypaver1, M. Weaver1, F. Mohammad1, A. Lee1, L. Kabbani1 1Henry Ford Health System, Division Of Vascular Surgery, Detroid, MI, USA
Introduction:
Fenestrated and branched aortic stent grafts have increased the endovascular solutions for complex aortic aneurysms. However, these specialized grafts may be anatomically incompatible or unavailable on an urgent/emergent basis. We present our early experience with in-situ laser fenestration (ISLF) of visceral vessels in various types of endovascular aortic aneurysm repair.
Methods:
All patients who underwent endovascular repair of an aortic aneurysm with additional laser fenestration of at least one visceral branch were retrospectively reviewed. Technical success was defined as successful aortic aneurysm repair with a patent laser fenestrated visceral branch. Postoperative morbidity and mortality, fluoroscopic time, radiocontrast volume and endoleak rate were reviewed.
Results:
Seven patients underwent ISLF of visceral aortic branches between March 2019 and July 2021. Mean age was 73.3 ± 4.2 years. Six out of seven patients (85%) were male. The ISLFs were as follows: 2 celiac arteries with thoracic endovascular aortic aneurysm repair (TEVAR); 1 superior mesenteric artery during suprarenal repair; 1 right renal artery during fenestrated EVAR; 1 right renal during EVAR, 1 left renal artery during EVAR, and 1 combined right and left renal artery during EVAR. All patients had sheath access of the targeted visceral vessel through an alternative access sites in preparation to perform a snorkel procedure, in case the laser fenestration failed (Figure 1). A stent was placed in the targeted vessel to fluoroscopically mark the origin of the vessel. After laser fenestration, serial dilation was preformed, and a covered stent graft (Icast, Atrium Medical Corporation) was deployed into the vessel, then flared. All procedures were technically successful with no arterial perforations and no evidence of type III endoleaks. Mean Fluoroscopy time was 81.8±28.3 minutes, and average contrast load was 186±43 cc. Postoperatively, there were no instances of renal insufficiency and no mortalities. Four patients had post-ISLF follow-up with Computed Tomography (CT) imaging (mean 17±9 weeks) demonstrating ISLF patency in all cases with no type III endoleaks.
Conclusion:
In our experience, ISLF of visceral aortic branches is a useful adjunct to the existing stent technologies. By allowing for extension of seal zones while maintaining anatomically aligned visceral vessel flow, ISLF increases our endovascular solutions for treating complex aortic aneurysms.
