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A 15 Year Experience With In Situ Laser Fenestration Of Arch Branches For Zones 0, 1 & 2 TEVAR: A Safe And Durable Technique
William Montgomery, MD, Fletcher Pierce MD, Fanny Alie-Cusson MD, Hosam F. El Sayed MD, Jean Panneton MD.
Eastern Virginia Medical School, Norfolk, VA, USA.
Objectives:In situ laser fenestration (ISLF) revascularization of the LSA during TEVAR. This study aims to evaluate long-term outcomes of ISLF of all aortic arch vessels during TEVAR to assess safety and durability.
Methods:This is a single center retrospective study of all consecutive patients who underwent ISLF for revascularization of aortic arch branches between 7/1/2009 and 7/1/2025. ISLF was performed by retrograde access, followed by covered stent deployment through the fenestration into the target vessel (LSA, LCCA, or innominate artery). Primary outcome was fenestration-related endoleaks (type Ic or IIIc). Secondary outcomes were stroke rate, branch stent patency, freedom from fenestration-related endoleak reintervention, and aortic-related mortality (ARM).
Results:A total of 101 patients with aortic arch pathology underwent TEVAR with ISLF of LSA (95), LCCA (4), innominate artery (3). 87 patients underwent zone-2, 9 zone-1, and 5 zone-0 TEVAR deployments. Median operative time was 162 minutes (range, 46-601). Technical success rate was 97% with 2 residual type Ia endoleaks at the completion of the index surgery and 1 failed LCCA fenestration requiring chimney. Indications included acute or chronic type-A or B dissections, PAU, acute IMH, degenerating aneurysms and BTAI with 24 aortic ruptures (23.8%). Early postoperative stroke rate was 3.9%, and no late stroke occurred at a mean clinical follow-up of 4.5 years (range, 0.1-15.2 yrs). 30-day operative mortality was 11.9%. At a mean imaging follow up of 4.2 years (range, 0.1-15.0), 3 patients (3.6%) were found to have a type 1c endoleak and underwent distal extension of the LSA stent at 6.6, 23.6, and 30.2 months postoperatively. Importantly, there were no fenestration-related type IIIc endoleak or mortality. Late ARM was 3.6%. Imaging showed 96.4% rate of stent patency in the late postoperative period. There were 3 instances of occluded LSA stents at 1.1, 3.8, and 6.1 years postoperatively, not requiring reintervention as the patients were asymptomatic. (
Table I).
Conclusions:In situ laser fenestration of aortic arch vessels during TEVAR especially in an urgent or emergent setting is a durable technique with high stent patency rate and very low fenestration related endoleaks and reinterventions with up to 15 years of postoperative follow up.
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