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

Objective: An analysis was conducted of early and midterm outcomes of a large series of patients treated with in situ laser fenestration (ISLF) during thoracic endovascular aortic repair (TEVAR) of acute and subacute complex aortic arch diseases, such as Stanford type A aortic dissection (TAAD), type B aortic dissection (TBAD) requiring proximal sealing at zone 2 or more proximal, thoracic aortic aneurysm or pseudoaneurysm, and penetrating aortic ulcer. We present the perioperative and follow-up outcomes and discuss the rate of complications. Methods: This is a retrospective review of prospectively collected data from January 2017 to March 2019 of patients treated with TEVAR and ISLF of aortic arch branches at a large tertiary academic institution in an urban city in China. Preoperative, intraoperative, and follow-up clinical and radiographic data are analyzed and discussed. Results: A total of 148 patients presented with symptomatic and acute or subacute TAAD, TBAD, thoracic aortic aneurysm, or penetrating aortic ulcer for a total of 183 arch vessels. There were 105 men and 43 women, 21 to 79 years of age (mean, 54.9 +/- 12.9 years). Time from symptom onset to time of surgery was an average of 7 6 3 days. Survivor follow-up duration ranged from 5 to 24 months (mean, 15 +/- 5 months). Single-vessel fenestration was carried out in 124 cases, twovessel fenestration in 13 cases, and three-vessel fenestration in 11 cases. There were four cases with technical failure to laser fenestration, with a technical success rate of 97.3%. Postoperatively, there were seven cases of endoleak (4.7%; one type IB distal from the left subclavian artery branch stent graft, three type IIIC at the fenestration site, and three type II), three retrograde dissections (2.0%), and five strokes (3.4%); death occurred in three patients with 30-day mortality of 2.9%, and two deaths occurred during follow-up for 3.4% mortality at an average 15 months of follow-up. There was no branch stent graft occlusion or spinal ischemia postoperatively or during follow-up. The distribution of arch diseases varied significantly according to the number of vessels that were laser fenestrated; TAAD was more likely to receive multivessel laser fenestrations, and TBAD was more likely to receive single-vessel fenestration (P < .001). The rate of complications was distributed differently between the three ISLF groups, with more complications occurring in multivessel fenestrations. However, a statistical weakening was observed when frequency of complications between the three groups was stratified by type of arch disease. The complication rate varied significantly between the different arch diseases, higher in TAAD than in TBAD (P = .008). Conclusions: ISLF during TEVAR for treatment of acute and subacute complex aortic arch diseases in the proximal aortic arch is safe and effective on the basis of these early to midterm follow-up data of a large cohort. However, care should be taken in intervening on TAAD using TEVAR with adjunctive multivessel laser fenestration. Continued investigation of TEVAR and adjunctive ISLF is needed to elucidate the long-term outcomes of this minimally invasive treatment for complex aortic arch disease in an urgent setting.