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• W2485725364 abstract "We report successful endovascular repair of a 61-year-old man treated for a 7.1-cm excentric aortic arch aneurysm by in situ stent graft fenestration for the brachiocephalic trunk and the left common carotid artery. Cerebral perfusion during the intervention was maintained by pump-driven extracorporal bypass to the right common carotid artery and to the left axillary artery provided with a left carotid-subclavian bypass. After 5 years of follow-up, the aortic arch in situ revascularization is still patent, the aneurysm excluded, and no endoleak detectable, although endovascular reintervention with distal aortic stent graft extension due to dilatation of the descending aorta was required. We report successful endovascular repair of a 61-year-old man treated for a 7.1-cm excentric aortic arch aneurysm by in situ stent graft fenestration for the brachiocephalic trunk and the left common carotid artery. Cerebral perfusion during the intervention was maintained by pump-driven extracorporal bypass to the right common carotid artery and to the left axillary artery provided with a left carotid-subclavian bypass. After 5 years of follow-up, the aortic arch in situ revascularization is still patent, the aneurysm excluded, and no endoleak detectable, although endovascular reintervention with distal aortic stent graft extension due to dilatation of the descending aorta was required. Aneurysms of the aortic arch can be treated by open surgery with extracorporal circulation, hybrid procedures with ascending aortic bypass, supra-aortic debranching, with endovascular aortic arch exclusion, or by using custom-made branched or fenestrated endografts.1Chuter T.A. Schneider D.B. Reilly L.M. Lobo E.P. Messina L.M. Modular branched stent graft for endovascular aortic repair of aortic arch aneurysm and dissection.J Vasc Surg. 2003; 38: 859-863Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar, 2Schoder M. Lammer J. Czerny M. Endovascular aortic arch repair: hopes and certainties.Eur J Vasc Endovasc Surg. 2009; 38: 255-261Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 3Malina M. Sonesson B. In situ fenestration: a novel option for endovascular aortic arch repair.J Cardiovasc Surg. 2015; 56: 355-362PubMed Google Scholar A multicenter series of patients with aortic arch aneurysms treated by endovascular repair using inner branched endografts was recently reported with promising results.4Houlon S. Greenberg R.K. Spear R. Eagleton M. Abraham C. Lioupis C. et al.Global experience with an inner branched arch endograft.J Thorac Cardiovasc Surg. 2014; 148: 1709-1716Abstract Full Text Full Text PDF PubMed Scopus (201) Google Scholar In situ fenestration of aortic stent grafts with antegrade perfusion of the brachiocephalic trunk and the left common carotid artery (CCA) might be another treatment option for exclusion of aortic arch pathologies as a total endovascular aortic repair or combined with partial supra-aortic debranching. So far, only few data of perioperative and short-term to midterm results of in situ fenestration for proximal aortic arch aneurysms are available, although an increasing number of patients were recently reported.5Sonesson B. Resch T. Allers M. Malina M. Endovascular total aortic arch replacement by in situ stent graft fenestration technique.J Vasc Surg. 2009; 49: 1589-1591Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 6Hongo N. Miyamoto S. Shuto R. Wada T. Matsumoto S. Kiyosue H. et al.Endovascular aortic arch reconstruction using in situ stent graft fenestration in the brachiocephalic artery.J Vasc Interv Radiol. 2011; 22: 1144-1148Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 7Eslami M.H. Sherburne A. Gupta A. Lazar H.L. Pump-assisted total arch replacement using an in situ stent graft fenestration technique.J Card Surg. 2014; 29: 816-820Crossref PubMed Scopus (6) Google Scholar, 8Hongo N. Miyamoto S. Shuto R. Wada T. Kamei N. Sato A. et al.“Squid-capture” modified in situ stent-graft fenestration technique for aortic arch aneurysm repair.Cardiovasc Intervent Radiol. 2014; 37: 1093-1098Crossref PubMed Scopus (23) Google Scholar, 9Tse L.W. Lindsay T.F. Roche-Nagele G. Oreopoulos G.D. Ouzounian M. Tan K.T. Radiofrequency in situ fenestration for aortic arch vessels during thoracic endovascular repair.J Endovasc Ther. 2015; 22: 116-121Crossref PubMed Scopus (73) Google Scholar, 10Katada Y. Kondo S. Tsuboi E. Rokkaku K. Irie Y. Yokoyama H. Endovascular total aortic arch repair using in situ fenestration for arch aneurysm and chronic type A dissection.Ann Thorac Surg. 2016; 101: 625-630Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 11Xiong J. Guo W. Liu X. Ma X. Wang L. Novel temporary endovascular shunt technique to assist in situ fenestration for endovascular reconstruction of the distal aortic arch.J Vasc Surg. 2015; 62: 226-228Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar However, long-term results are missing. Therefore, we report chronologically the second patient treated by in situ aortic arch stent graft fenestration for an aortic arch aneurysm with probably the longest follow-up period available so far and emphasize the need for regular long-term surveillance. A 61-year-old man with a 7.1-cm-diameter aortic arch aneurysm located at the inner curvature of the aortic arch was treated by in situ aortic stent graft fenestration for antegrade perfusion of the brachiocephalic trunk and the left CCA (Fig 1). The patient underwent an aortocoronary bypass operation 1 year before that included a left mammary artery bypass. The patient was considered unfit for reoperation with open aortic arch repair, and informed consent was obtained for this off-label procedure. Before the intended endovascular aortic arch intervention, the patient received a left carotid-subclavian bypass. During the endovascular aortic arch intervention, cerebral perfusion was maintained by extracorporal circulation with bypass to the left axillary artery and the right CCA under moderate hypothermia of 31°C. In situ fenestrations in the tapered aortic stent graft implanted into the aortic arch (Cook Zenith 42-38 mm, 153 mm; Cook Europe, Bjaeverskov, Denmark) were performed by insertion of short 8F sheaths into both CCAs and puncture of the aortic arch stent graft with 18-gauge 18-cm access needles (Cook Europe) under fluoroscopic control with different planes perpendicular to the stent graft. The puncture sites were then dilated using a 4-mm high-pressure balloon, a 6-mm cutting balloon for the left CCA and another 8-mm high-pressure balloon for the brachiocephalic trunk. For implantation of the connecting stent grafts, two 12- × 41-mm Advanta V12 stent grafts (Maquet, Rastatt, Germany) were used and aligned with a 12- × 25-mm Express stent (Boston Scientific, Ratingen, Germany) for the brachiocephalic trunk and a 7- × 38-mm Advanta stent graft for the left CCA, additionally aligned with an 8- × 18-mm Genesis Palmaz stent (Cordis, Fremont, Calif; Fig 2). Time of extracorporal perfusion to the left axillary artery was 260 minutes and to the right CCA was 200 minutes, with a flow of 350 to 500 mL/min. The patient's postoperative outcome was uneventful, and he was discharged after 8 days with complete aneurysm exclusion, absence of endoleak, and without neurologic complications. The patient had follow-up examinations after 6 months and then at yearly intervals. A computed tomography angiogram after 5 years showed a dilatation and elongation of the proximal descending aorta with nonalignment of the distal aortic stent graft requiring aortic stent graft extension using a custom made 40-36-92-mm endograft further extended with a 42- × 36- × 160-mm stent graft (both Cook, Zenith ZDEG stent grafts; Fig 3). Patient consent was obtained for this case presentation. The first patient treated by in situ aortic arch fenestrations for an aneurysm of the aortic arch was reported by Sonesson et al5Sonesson B. Resch T. Allers M. Malina M. Endovascular total aortic arch replacement by in situ stent graft fenestration technique.J Vasc Surg. 2009; 49: 1589-1591Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar in 2009, with successful aneurysm exclusion of a patient with a ruptured aortic arch plaque. According to the literature, 13 patients were treated by in situ stent graft fenestration for aortic arch aneurysms with total or partial endovascular aortic arch repair at six different institutions between 2009 and 2015.5Sonesson B. Resch T. Allers M. Malina M. Endovascular total aortic arch replacement by in situ stent graft fenestration technique.J Vasc Surg. 2009; 49: 1589-1591Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 6Hongo N. Miyamoto S. Shuto R. Wada T. Matsumoto S. Kiyosue H. et al.Endovascular aortic arch reconstruction using in situ stent graft fenestration in the brachiocephalic artery.J Vasc Interv Radiol. 2011; 22: 1144-1148Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 7Eslami M.H. Sherburne A. Gupta A. Lazar H.L. Pump-assisted total arch replacement using an in situ stent graft fenestration technique.J Card Surg. 2014; 29: 816-820Crossref PubMed Scopus (6) Google Scholar, 8Hongo N. Miyamoto S. Shuto R. Wada T. Kamei N. Sato A. et al.“Squid-capture” modified in situ stent-graft fenestration technique for aortic arch aneurysm repair.Cardiovasc Intervent Radiol. 2014; 37: 1093-1098Crossref PubMed Scopus (23) Google Scholar, 9Tse L.W. Lindsay T.F. Roche-Nagele G. Oreopoulos G.D. Ouzounian M. Tan K.T. Radiofrequency in situ fenestration for aortic arch vessels during thoracic endovascular repair.J Endovasc Ther. 2015; 22: 116-121Crossref PubMed Scopus (73) Google Scholar, 10Katada Y. Kondo S. Tsuboi E. Rokkaku K. Irie Y. Yokoyama H. Endovascular total aortic arch repair using in situ fenestration for arch aneurysm and chronic type A dissection.Ann Thorac Surg. 2016; 101: 625-630Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 11Xiong J. Guo W. Liu X. Ma X. Wang L. Novel temporary endovascular shunt technique to assist in situ fenestration for endovascular reconstruction of the distal aortic arch.J Vasc Surg. 2015; 62: 226-228Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Most patients treated so far were single interventions and published as a case report. Just recently, the largest patient series was reported with seven patients treated by in situ aortic arch fenestrations, four of them performed as complete endovascular aortic arch repair.10Katada Y. Kondo S. Tsuboi E. Rokkaku K. Irie Y. Yokoyama H. Endovascular total aortic arch repair using in situ fenestration for arch aneurysm and chronic type A dissection.Ann Thorac Surg. 2016; 101: 625-630Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar Interestingly, the authors have treated three patients by in situ aortic arch stent graft fenestration with intimal tears in the ascending aorta. What are the indications to use in situ aortic arch fenestration in times of upcoming procedures such as inner branch endografts, aortic arch chimney procedures, and ascending aortic bypass to supra-aortic arteries with partial sternotomy and supra-aortic debranching? As a less invasive endovascular procedure, aortic arch in situ stent graft fenestration is an option in emergency procures when custom-made endografts are not available or in patients with large ascending aortic diameters or a short proximal landing zone in the ascending aorta where chimney graft interventions are not suitable. However, in situ fenestrated stent grafts are at an increased risk for type III endoleaks because the connecting stent graft has only a very short zone for sealing and requires a close apposition to the aortic wall. Therefore, in situ fenestration within the aortic arch is recommended only for aortic pathologies or aneurysms located at the inner curvature of the aortic arch with alignment and apposition of the stent graft at the outer curve of the aorta.3Malina M. Sonesson B. In situ fenestration: a novel option for endovascular aortic arch repair.J Cardiovasc Surg. 2015; 56: 355-362PubMed Google Scholar, 8Hongo N. Miyamoto S. Shuto R. Wada T. Kamei N. Sato A. et al.“Squid-capture” modified in situ stent-graft fenestration technique for aortic arch aneurysm repair.Cardiovasc Intervent Radiol. 2014; 37: 1093-1098Crossref PubMed Scopus (23) Google Scholar, 10Katada Y. Kondo S. Tsuboi E. Rokkaku K. Irie Y. Yokoyama H. Endovascular total aortic arch repair using in situ fenestration for arch aneurysm and chronic type A dissection.Ann Thorac Surg. 2016; 101: 625-630Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar Because relevant data on durability and long-term outcome are not yet available, we consider in situ aortic arch fenestration as an option for very selected patients after primary evaluation of fenestrated, branched, or chimney stent grafts for endovascular aortic arch repair. According to the reports in the literature, most retrograde punctures and in situ stent graft fenestrations to the brachiocephalic trunk and the left CCA were performed by needle punctures as the most straightforward procedure. In other series, in situ fenestrations for perfusion of the left subclavian artery (LSA) were performed by laser or radiofrequency catheters to overcome the more tortuous and kinked course of the LSA.12Redlinger R.E. Ahanchi S.S. Panneton J.M. In situ laser fenestration during emergent thoracic endovascular aortic repair is an effective method for left subclavian artery revascularization.J Vasc Surg. 2013; 58: 1171-1177Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar Over time, several technical modifications were included to improve technical success and facilitate the in situ aortic arch fenestration procedure. To avoid extracorporal circulation during the time of retrograde in situ fenestration of the stent graft and occlusion of the supra-aortic vessels, others have used retrograde supra-aortic perfusion via an extra-anatomic bypass from the common femoral to the left axillary artery or left CCA with additional supra-aortic debranching.6Hongo N. Miyamoto S. Shuto R. Wada T. Matsumoto S. Kiyosue H. et al.Endovascular aortic arch reconstruction using in situ stent graft fenestration in the brachiocephalic artery.J Vasc Interv Radiol. 2011; 22: 1144-1148Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar The “squid capture” technique was introduced by Kongo et al8Hongo N. Miyamoto S. Shuto R. Wada T. Kamei N. Sato A. et al.“Squid-capture” modified in situ stent-graft fenestration technique for aortic arch aneurysm repair.Cardiovasc Intervent Radiol. 2014; 37: 1093-1098Crossref PubMed Scopus (23) Google Scholar and allows more stable retrograde puncturing of the aortic stent graft, which is snared and fixed to the aortic arch wall by a wire loop. Another option to maintain cerebral perfusion was investigated in experimental studies and reported in one patient with in situ stent graft fenestrations for the left CCA and LSA with supra-aortic perfusion using intraluminal shunts for retrograde perfusion from the descending aorta to both CCAs.11Xiong J. Guo W. Liu X. Ma X. Wang L. Novel temporary endovascular shunt technique to assist in situ fenestration for endovascular reconstruction of the distal aortic arch.J Vasc Surg. 2015; 62: 226-228Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 13Sonesson B. Resch T. Diaz N. Malina M. New temporary internal introducer shunt for brain perfusion during total endovascular arch replacement with in situ fenestration technique.J Vasc Surg. 2012; 56: 1162-1165Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Long-term durability is an essential end point to support the concept of endovascular aortic arch repair, and long-term data after in situ aortic arch fenestration are still missing. To the best of our knowledge, the patient reported here seems to be one of the patients with the longest follow-up period available so far. In our patient, however, dilatation and elongation of the proximal descending aorta was observed after >60 months, with stent graft nonalignment requiring reintervention with distal aortic stent graft extension. Although the connecting supra-aortic stent grafts were patent without an endoleak and the aneurysm was still excluded with reduced diameter supporting long-term durability of aortic arch in situ fenestration, lifelong surveillance is mandatory to detect changes related to physiologic aortic degeneration. The patient presented in this report was successfully treated for his large aortic arch aneurysm by in situ stent graft fenestration with complete aneurysm exclusion, absence of endoleak, and patent connecting stent grafts during long-term follow-up. However, physiologic aortic degeneration with aortic elongation and dilatation has to be considered, requiring lifelong regular surveillance with evaluation for secondary endovascular reinterventions." @default.
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• W2485725364 title "Long-term durability of aortic arch in situ stent graft fenestration requiring lifelong surveillance" @default.
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