Fenestrated Thoracic Endovascular Aortic Repair Using Physician-Modified Stent Grafts (PMSGs) in Zone 0 and Zone 1 for Aortic Arch Diseases

PurposeTo evaluate the outcomes of fenestrated thoracic endovascular aortic repair (f-TEVAR) using physician-modified stent grafts (PMSGs) in zone 0 and zone 1 for aortic arch diseases.Methodsf-TEVAR using PMSGs in Z0 and Z1 was performed on ten high-risk patients for open surgery from November 2015 to September 2017. Indications were complicated acute type B dissection (ABAD) with retrograde dissection involving the mid-arch (n=1), distal arch aneurysms (n=3), mid-arch aneurysms of the inner arch curvature (n=3) and penetrating aortic ulcer located in the mid- or proximal arch (n=3). Pre-, intra- and postoperative clinical data were recorded.ResultsThe median patient age was 61 (range 45-81) years, and 9 (90%) patients were men. Ten PMSGs (Medtronic Valiant stent grafts, n=1; Relay thoracic stent grafts, n=4; Cook TX2 device, n=5) were deployed. PMSGs were deployed from Z0 and Z1 in 5 and 5 patients, respectively. Double small fenestrations for the left subclavian artery (LSA) and the left common carotid artery (LCCA), respectively, were created in 3 patients. Triple small fenestrations for the innominate artery (IA), the LCCA and the LSA, respectively, were created in 2 patients. One large fenestration for both the IA and the LCCA combined with one small fenestration for the LSA was created in 3 patients. One large fenestration for the LCCA combined with one small fenestration for the LSA was created in 2 patients. Posterior diameter-reducing ties were added to all the devices except to one Valiant stent graft. All but 2 patients underwent elective procedure. Median duration for stent graft modifications was 105 (range 90-125)min. The technical success rate was 90%. Overall mortality was 10% (1/10). One patient died of sudden cardiac arrest intraoperatively after the deployment of the PMSG and all the supra-aortic branch stents. Mean operative time was 106.043.0min, and fluoroscopy time was 30.6 +/- 22.9min. There were no type I or type III endoleaks, perioperative neurological complications or spinal cord ischemia. Median length of stay was 8 (range 4-35) days. Nine patients survived at mean 13.3 (range 6.0-19.0) months follow-up. Retrograde dissection occurred in one patient of Z0 group 40days post-f-TEVAR and resolved after open repair. During follow-up, all target vessels remained patent without fenestration-related type I or III endoleaks.Conclusions f-TEVAR using PMSGs in Z0 and Z1 for the treatment of aortic arch diseases in high-risk patients is feasible in the hands of experienced operators.