Revascularization of the Left Subclavian Artery During TEVAR Utilizing a Percutaneous In-situ Technique

BACKGROUND: To report the use of retrograde in-situ laser-assisted endograft fenestration during thoracic endovascular aortic repair.
METHODS: A 69 year old gentleman presented with a pseudoaneurysm just distal to the left subclavian artery. Ten years previously he was involved in a motor vehicle accident. He was complaining of chest pain and left shoulder pain. During the work-up of acute coronary syndrome a peripherally calcified pseudoaneurysm measuring up to 3.9 cm involving the posteriomedial aspect of the distal aortic arch was identified (Figure 1). Old fractures of the pubic rami, left ribs, and left clavicle were also identified compatible with prior chest trauma.
RESULTS: Endovascular thoracic aneurysm repair was elected with revascularization of the left subclavian artery. The patient had a dominant left vertebral and also was left hand dominant. Because of the clavicular fracture and multiple rib fractures on the left, in-situ stent graft fenestration was performed rather than carotid subclavian bypass to avoid the area of previous trauma. The proximal and distal neck landing zones measured 31 mm in diameter. The proximal neck length was only 10 mm distal to the left subclavian artery necessitating coverage. A 36 mm Talent (Medtronic, Santa Rosa, CA) thoracic stent-graft was deployed, with the covered portion extending to the left carotid artery with the free-flo spring over the left carotid artery. A 2.3 mm Turbo excimer laser (Spectranetics, Colorado Springs, Colorado) was advanced through a 7F sheath from a left brachial approach and utilized to fenestrate the stent graft under flouroscopic guidance. The fenestration was dilated and stented with a 8x38 mm iCast stent (Atrium, Hudson, NH) (Figure 2). The stent was flared proximally and distally for seal. The patient tolerated the procedure well and was discharged home on the second postoperative day. There was no pressure gradient between upper extremities on follow-up evaluation with the aneurysm being completely excluded with a widely patent left subclavian stent (Figure 3 and 4). The patients left chest and shoulder pain completely resolved.
CONCLUSIONS: In situ fenestration utilizing the excimer laser allows for rapid branch management of the aortic arch vessels and minimizes the need for surgical reconstructions. Furthermore, this technique may be helpful as a bailout maneuver for a misplaced endograft. The long-term durability of this procedure is unknown and requires further study.