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 VS2. Thoracic Endovascular Aortic Repair with Left Subclavian Artery Laser Fenestration

​Sadaf S. Ahanchi, Jean M. Panneton
Department of Surgery Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, VA.

BACKGROUND: A significant need exists for a versatile and accessible method to revascularize aortic branches during thoracic endovascular aortic repair (TEVAR). We present a video of an emergent zone II TEVAR with revascularization of the left subclavian artery (LSCA) with retrograde laser fenestration.

TECHNICAL DESCRIPTION: We present a 58-year-old African American female with a symptomatic thoracic aortic aneurysm secondary to a chronic type B thoracic aortic dissection. Emergent TEVAR was carried out using Captiva (Medtronic, Minneapolis, MN) endografts. The proximal endograft was positioned immediately distal to the bovine arch orifice of the innominate and left carotid arteries. Through retrograde left open brachial artery access, we placed an 8.5 French St. Jude lamp septal, 45 degree sheath (St. Jude Medical, Saint Paul, MN), which provides a gentle preformed angle at the tip. An 0.018” Platinum Plus wire (Boston Scientific, Natick, MA) through a 2.5mm laser catheter (Spectranetics, Colorado Springs, CO) were then placed at the ostium of the LSCA perpendicular to the endograft. After deployment of the endograft, laser energy of 45 millijoules/mm2 at 25 pulses/second was applied in conjunction with gentle laser-endograft contact pressure for 3-5 seconds to create a fenestration. The 0.018” wire was then advanced through the laser catheter into the endograft lumen and exchanged for a stiff 0.035” wire. After endograft predilation using a 6mm balloon, an ICAST covered 9x38mm balloon expandable stent (Atrium, Hudson, NH) was deployed approximately ¼ into the lumen and ¾ into the branch vessel. The endograft portion of the covered stent was then flared. Finally, completion aortograms were performed to demonstrate TEVAR and left SCA fenestration patency with no endoleaks. Computed tomography angiography (CTA) was performed prior to discharge and at 1-3 month intervals post procedure to assess for TEVAR and left SCA fenestration patency, endoleak, and aneurysm/dissection exclusion.

AUTHOR DISCLOSURES: S. S. Ahanchi, Nothing to disclose; J. M. Panneton, Spectranetic, Consulting fees or other remuneration (payment), Medtronic, Consulting fees or other remuneration (payment).

Posted April 2012

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