Emergent In Situ Fenestration in the Ascending Aorta for the Endovascular Repair of a Large Pseudoaneurysm: A Technical Note

Abstract

Purpose:

The purpose of this article is to describe an emergent in situ fenestration (ISF) technique in the ascending aorta for the endovascular repair of a large pseudoaneurysm using a trans-septal needle device through direct right common carotid artery access, in a patient with left ventricular assist device (LVAD).

Technique:

We performed, in a multidisciplinary team-work approach, an emergent ISF to correct the displacement of a physician-modified thoracic endograft released in the ascending aorta to correct a large anastomotic pseudoaneurysm in a patient who underwent ascending aorta replacement and subsequent LVAD implantation. We used a trans-septal needle device inserted through a direct access to the right carotid artery and performed an ISF to restore the patency of the outflow ostium of the LVAD. Window was then completed and stabilized with a nitinol balloon expandable covered stent graft obtaining an effective exclusion of the anastomotic aortic aneurism and the regular patency of the LVAD outflow graft with no signs of leaks.

Conclusions:

Multidisciplinary teamwork approach can be crucial in challenging procedures where an alternative approach may lead to problem solving. The ISF technique may be a valid option to adopt in emergency cases in which no other technical solutions are suitable.

Clinical Impact

The endovascular approach has become more and more frequent for the treatment of vascular pathologies, getting increasingly refined and complex. Thereby the chance of incurring intraprocedural troubles has grown and bailout strategies should always be present. In situ fenestration is a technique to be aware of and that could help you recover from difficult situations. We report a possible rescue maneuver that can be applied also in arduous anatomies such as the ascending aorta. Moreover, we would like to highlight the importance of a multidisciplinary working environment that can enrich our everyday practice accomplishing effective and unexpected solutions.

Keywords

aortic aneurysm*ascending aorta common carotid artery covered stent graft custom-made device endovascular treatment/therapy endovascular aneurysm repair fenestration off-label use urgent procedure

Get full access to this article

View all access options for this article.

References

Bosse

Kölbel

Mougin

, et al. Off-the-shelf multibranched endograft for total endovascular repair of the aortic arch. J Vasc Surg. 2020;72(3):805–811. doi:10.1016/j.jvs.2019.11.046.

Reyes Valdivia

Pitoulias

, et al. Systematic review on the use of physician-modified endografts for the treatment of aortic arch diseases. Ann Vasc Surg. 2020;69:418–425.doi:10.1016/j.avsg.2020.07.040.

Yan

Shi

Qin

, et al. Outcomes of emergency in situ laser fenestration-assisted thoracic endovascular aortic repair in patients with acute Stanford type A aortic dissection unfit for open surgery. J Vasc Surg. 2020;71(5):1472–1479. doi:10.1016/j.jvs.2019.08.233.

Glorion

Coscas

McWilliams

, et al. A comprehensive review of in situ fenestration of aortic endografts. Eur J Vasc Endovasc Surg. 2016;52(6):787–800. doi:10.1016/j.ejvs.2016.10.001.

Chan

Jia

, et al. Methods and clinical outcomes of in situ fenestration for aortic arch revascularization during thoracic endovascular aortic repair. Vascular. 2020;28(4):333–341. doi:10.1177/1708538120902650.

Crawford

Sanford

Forbes

, et al. Clinical outcomes and material properties of in situ fenestration of endovascular stent grafts. J Vasc Surg. 2016;64(1):244–250. doi:10.1016/j.jvs.2016.03.445.

Chen

, et al. Endovascular in situ fenestration technique of aortic arch pathology: a systematic review and meta analysis. Ann Vasc Surg. 2021;76:472–480. doi:10.1016/j.avsg.2020.12.021.

Redlinger

Jr Ahanchi

Panneton

JM.

In situ laser fenestration during emergent thoracic endovascular aortic repair is an effective method for left subclavian artery revascularization. J Vasc Surg. 2013;58(5):1171–1177. doi:10.1016/j.jvs.2013.04.045.

Ahanchi

Almaroof

Stout

, et al. In situ laser fenestration for revascularization of the left subclavian artery during emergent thoracic endovascular aortic repair. J Endovasc Ther. 2012;19(2):226–230. doi:10.1583/11-3770MR.1.

10.

Wang

Bai

, et al. In situ laser fenestration for delayed left subclavian artery revascularization following thoracic endovascular aortic repair of Type B aortic dissection. Vasc Endovascular Surg. 2021;55(8):851–855. doi:10.1177/15385744211010386.

11.

Zhao

Qin

Yin

, et al. In situ laser stent graft fenestration of the left subclavian artery during thoracic endovascular repair of type B aortic dissection with limited proximal landing zones: 5-year outcomes. J Vasc Interv Radiol. 2020;31(8):1321–1327. doi:10.1016/j.jvir.2020.02.025.

12.

Qin

Zhao

Wang

, et al. In situ laser fenestration is a feasible method for revascularization of aortic arch during thoracic endovascular aortic repair. J Am Heart Assoc. 2017;6(4):e004542. doi:10.1161/JAHA.116.004542.

13.

Hua

, et al. Early and midterm outcomes of in situ laser fenestration during thoracic endovascular aortic repair for acute and subacute aortic arch diseases and analysis of its complications. J Vasc Surg. 2020;72(5):1524–1533. doi:10.1016/j.jvs.2020.01.072.

14.

Morton

Masters

Cowburn

PJ.

Multidisciplinary team approach to heart failure management. Heart. 2018;104(16):1376–1382. doi:10.1136/heartjnl-2016-310598.

15.

Kesson

Allardice

George

, et al. Effects of multidisciplinary team working on breast cancer survival: retrospective, comparative, interventional cohort study of 13 722 women. BMJ. 2012;344:e2718. doi:10.1136/bmj.e2718.