Background:

Open aortic repair is the gold standard in the treatment of diseases involving the aortic arch, but high-risk patients are often not suitable candidates for surgical repair. Thoracic endovascular aortic repair (TEVAR) is less invasive; however, endovascular repair including the aortic arch remains a challenge.

LSA revascularization is linked with reduced risk of cerebrovascular events, spinal cord ischemia, and upper limb ischemia at the cost of complications associated with carotid-subclavian bypass. In-situ fenestration (ISF) seems an effective, safe, and feasible method for the totally endovascular aortic arch repair avoiding the risks associated with bypass surgery. This technique allows for rapid, “off-the-shelf” repair of arch lesions with minimal physiologic disturbances and lower perioperative complications.

Case report:

An 86-year-old man is admitted to the emergency room due to chest pain and hoarseness. There was a previous medical history of TEVAR (proximally implanted in zone 3) for penetrating thoracic aortic; 8 months prior. Computed tomography angiography revealed aneurysmal dilation of the lesser curvature of the aortic arch with a maximum diameter of 65mm. The patient was submitted to TEVAR with proximal sealing in zone 2 of the arch (Ankura™ stent-graft) and revascularization of the left subclavian artery (LSA) was achieved using an ISF by needle fenstration with the deployment of a balloon-expandable covered stent. No complications were registered. Patient initiated broad spectrum antibiotics and underwent positron emission tomography revealing several metabolically active lymph nodes suggesting underlying neoplasm.

Conclusion:

ISF, due to its relative simplicity, is also suitable in urgent and emergent settings. It is a simple, quick technique to be added to our arsenal of endovascular procedures on the aortic arch. It may avoid the carotid-subclavian bypass as well as intentional embolization of the LSA in urgent/emergent patients. Prospective studies with long-term clinical follow-up are still lacking to fully assess the durability of these fenestrations.

        · texto em Inglês     · Inglês ( pdf )