Techniques and Results of Endovascular In Situ Arch Fenestrations

Abstract

Thoracic endovascular aortic repair (TEVAR) has been widely applied to treat acute and chronic diseases of the aorta. Successful endovascular repair of the thoracic aorta requires adequate proximal and distal apposition of the endograft to healthy aorta. To achieve a good proximal seal, this can require coverage of one or more of the aortic arch vessels. In situ arch fenestration is an endovascular technique that involves endovascular modification of a thoracic endograft to achieve arch vessel revascularization. This is most commonly applied to the left subclavian artery (LSA) but can be utilized in any arch vessel. Fenestration of a thoracic endograft can be performed with needle puncture, laser energy, or radiofrequency wire followed by balloon angioplasty of the fenestration and placement of a covered stent across the endograft fenestration into the target vessel. Technical success of this method is most limited by aortic arch type, angulation of arch vessels, and target vessel anatomy. This chapter describes the technical aspects and results of in situ arch fenestration, history, pathology, anatomic limitations, patient selection, different methods of fenestration, a complex case, and application of new endovascular tools.