In situ laser fenestration for revascularization of the left subclavian artery during emergent thoracic endovascular aortic repair.

PURPOSE: To present midterm outcomes of thoracic endovascular aortic repair (TEVAR) with laser fenestration to revascularize the left subclavian artery (LSA) as an alternative to debranching.

METHODS: Six symptomatic patients (3 men; mean age of 50 years) underwent emergent TEVAR with LSA revascularization via laser graft fenestration. Three patients had large thoracic aortic aneurysms (2 secondary to chronic dissection); 1 patient had an acute symptomatic type B aortic dissection, and 2 patients had intramural hematomas. Emergent TEVAR was carried out with deployment of a Dacron endograft over the orifice of the left LSA. Through retrograde brachial access, a 0.018-inch wire was placed at the ostium of the LSA followed by laser catheter fenestration of the graft. A 10-mm covered stent was deployed through the fenestration to traverse the endograft and LSA; the endograft portion of the covered stent was flared.

RESULTS: Laser fenestration was successful in 5 of 6 attempts; 1 fenestration was abandoned secondary to an acute LSA takeoff in a type III aortic arch. In this case, the stent was placed as a snorkel to successfully revascularize the LSA with no adverse consequences. There were no fenestration-related complications and no neurological morbidity. At a mean 8-month follow-up (range 1-17), no patients had died, and all LSA stents were patent, with no fenestration-related endoleaks on imaging.

CONCLUSION: In situ retrograde laser fenestration is a feasible and effective option for revascularizing the LSA during emergent TEVAR. Longer follow-up is necessary to determine the durability of this technique.