A Series Of Clinical Researches On Total Percutaneous In Situ Micro-Needle Based Fenestration Technique For The Treatment Of Aortic Arch Diseases With Inappropriate Proximal Landing Zone

BackgroundThoracic endovascular aortic repair(TEVAR)has been widely used nowadays and has been the first choice for the treatment of descending aortic disease.However,for complex lesions involving the aortic arch,it is often necessary to extend the landing zone to zone2 to zone0.The coverage of the origin of the arch vessels,potentially lead to cerebrovascular ischemia and stroke.Revascularization of aortic arch vessels is important and challenge.Different techniques for revascularization have been reported.Many of these techniques require surgical incision and the use of special instruments.When lesions involving the revascularization of the three branches of the aortic arch,it requires brain protection measures to limit its clinical application in complex aortic lesions involving the aortic arch.TEVAR for lesions involving the aortic arch extend the landing zone to zone 0,and it requires cervical branch reconstruction,certain issues remain unaddressed.ObjectiveTo establish a total percutaneous in situ micro-puncture technique,and analyze the safety and efficacy of its applications on reconstruction of the blood flow of left subclavian artery,left common carotid artery and brachiocephalic artery during TEVAR.Materials and methods1.Between December 2018 to January 2023,172 consecutive patients with complex thoracic aortic diseases with inappropriate proximal landing zone who were treated with TEVAR with in situ LSA fenestration were retrospectively enrolled in this study.2.A retrospective study was conducted of consecutive patients who underwent TEVAR for patients with TBAD involving the Zone 2.From October 2018 to April 2022,a total of 202 patients treated with either C-TEVAR(n=89)or ISMNPF-TEVAR(n=113).3.12 patients with complex thoracic aortic diseases were treated with TEVAR with in situ micro needle fenestration for the reconstruction of the left common carotid artery,brachiocephalic artery and LSA.Results1.LSA was successfully reconstructed in 172 patients,with a success rate of 100%.The mean follow-up period was 20.35 ± 10.6 months.No endoleak,branch stent occlusion,fracture and displacement of the branch stent occurred.2.The technical success rate was 84.3%in the chimney group and 93.8%in the ISMNPF group(P=0.027).The incidence of immediate endoleak in the chimney group was significantly higher than that in the ISMNPF group(21/202,15.7%vs 6.2%,P=0.027).The 1-year and 3-year survival rates of chimney group and ISMNPF group were 98.9 ± 1.1%vs 98.1±0.9%and 86.5 ± 6.3%vs 92.6 ± 4.1%,respectively(log-rank P=0.715).3.Technical success was achieved in all cases(100%).Postoperative complications included cerebral infarction in one patient(8.3%),and no puncture-related complications occurred.The mean follow-up period was 12.08±6.2 months,there was one patient died(8.3%).Conclusions1.In situ micro-needle fenestration during TEVAR via the LSA approach is a feasible and effective method for LS A reconstruction.2.Both Fenestration-TEVAR and chimney-TEVAR achieved satisfactory short and mid-term outcomes for preservation of the LSA in TBAD.The fenestration group had lower reintervention rate with higher patency than chimney group.However,fenestration-TEVAR need a longer operation and fluoroscopy time with higher procedure expense.3.The technique of totally percutaneous in situ micro-puncture fenestration is a safe and effective technique in reconstruction of three branches of aortic arch during TEVAR.The gutter sheaths technique enables safe and reliable fenestration.