Single- and Double-Fenestrated Physician-Modified Stent Grafts for Emergent Aortic Arch Lesions

Abstract

Objective:

To evaluate and compare outcomes of single- and double-fenestrated physician-modified endovascular grafts (PMEGs) for aortic arch pathologies treated in an emergent setting.

Methods:

All patients consecutively treated for an emergent aortic arch pathology were included in this retrospective single-center cohort study between July 2014 and March 2023. In each case, the distal smaller fenestration for the left subclavian artery (LSA) was the only 1 stented. For a double-fenestrated endograft, a proximal larger fenestration that incorporated both the brachiocephalic trunk and the left common carotid artery was added.

Results:

A total of 86 patients with complicated aortic arch lesions were treated, with 74% being men and a mean age of 68 years. Of these, 63% underwent single LSA fenestration, while 37% had double-fenestrated thoracic endovascular aortic repair. The main indications for repair included acute complicated type B aortic dissection (TBAD) (54%), traumatic transection of the aorta (TTA) (19%), and other conditions such as penetrating aortic ulcer (PAU), degenerative aneurysm (DA), pseudoaneurysm (PSA), and aortic thrombus. The technical success rate was 91%, with modification times of 10 minutes for single fenestration and 23 minutes for double fenestration. Thirty-day mortality was 19%, with no significant difference between the 2 fenestration types. Neurologic events occurred in 3 patients (3%), and 3 (3%) patients had perioperative retrograde dissection. Endoleaks occurred in 5% (type 1) and 2% (type 3), with no type 2 endoleaks. Eight patients (9%) required reintervention, and all supra-aortic trunks remained patent. During a follow-up of 27.6 months, no patients experienced aortic rupture (AR), neurological events, or required conversion to open surgery.

Conclusion:

Single and double PMEGs are suitable and reproducible treatment for emergent serious aortic arch lesions, with comparable outcomes whatever the aortic landing zone and number of fenestrations.

Clinical Impact

Fenestrated physician-modified endovascular grafts for emergent aortic arch repair appear to be a promising treatment, offering reproducibility, rapid deployment, and limited manipulation of supra-aortic trunks. The standardized technique eliminates the need for complex sizing and benefits from consistent aortic arch anatomy in most patients. It provides clinicians with a practical and efficient option in emergency settings, achieving high technical success with acceptable complication rates.

Keywords

aortic arch physician-modified stent graft thoracic aorta TEVAR F-TEVAR off-the-shelf emergent surgery

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References

Czerny

Schmidli

Adler

, et al. Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European association for cardio-thoracic surgery (EACTS) & the European society for vascular surgery (ESVS). Eur J Vasc Endovasc Surg. 2019;57:165–198.

Hiratzka

Bakris

Beckman

, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American college of cardiology foundation/American heart association task force on practice guidelines, American association for thoracic surgery, American college of radiology, American stroke association, society of cardiovascular anesthesiologists, society for cardiovascular angiography and interventions, society of interventional radiology, society of thoracic surgeons, and society for vascular medicine. Circulation. 2010;121:e266–e369.

Patel

Nguyen

Diener

, et al. Open arch reconstruction in the endovascular era: analysis of 721 patients over 17 years. J Thorac Cardiovasc Surg. 2011;141(6):1417–1423.

Gandet

Ozdemir

Trubert

, et al. Physician-modified thoracic stent grafts for the arch after surgical treatment of type A dissection. Ann Thorac Surg. 2019;108(2):491–498.

Canonge

Jayet

Heim

, et al. Comprehensive review of physician modified aortic stent grafts: technical and clinical outcomes. Eur J Vasc Endovasc Surg. 2021;61(4):560–569.

Canaud

Baba

Gandet

, et al. Physician-modified thoracic stent-grafts for the treatment of aortic arch lesions. J Endovasc Ther. 2017;24(4):542–548.

Chastant

Belarbi

Ozdemir

, et al. Homemade fenestrated physician-modified stent grafts for arch aortic degenerative aneurysms. J Vasc Surg. 2022;76(5):1133–1140.

Yoon

Mell

. Outcome comparison of thoracic endovascular aortic repair performed outside versus inside proximal landing zone length recommendation. J Vasc Surg. 2020;72(6):1883–1890.

Riambau

Böckler

Brunkwall

, et al. Editor’s choice—management of descending thoracic aorta diseases. Eur J Vasc Endovasc Surg. 2017;53(1):4–52.

10.

Ouzounian

LeMaire

Coselli

. Open aortic arch repair: state-of-the-art and future perspectives. Semin Thorac Cardiovasc Surg. 2013;25(2):107–115.

11.

Settepani

Cappai

Basciu

, et al. Outcome of open total arch replacement in the modern era. J Vasc Surg. 2016;63(2):537–545.

12.

Beckmann

Martens

Kaufeld

, et al. Is total aortic arch replacement with the frozen elephant trunk procedure reasonable in elderly patients? Eur J Vasc Endovasc Surg. 2021;60(1):131–137.

13.

Moulakakis

Mylonas

Markatis

, et al. A systematic review and meta-analysis of hybrid aortic arch replacement. Ann Cardiothorac Surg. 2013;2(3):247–260.

14.

De Rango

Cao

Ferrer

, et al. Aortic arch debranching and thoracic endovascular repair. J Vasc Surg. 2014;59(1):107–114.

15.

Yoshitake

Hachiya

Okamoto

, et al. Postoperative stroke after debranching with thoracic endovascular aortic repair. Ann Vasc Surg. 2016;36:132–138.

16.

Dueppers

Reutersberg

Rancic

, et al. Long-term results of total endovascular repair of arch-involving aortic pathologies using parallel grafts for supra-aortic debranching. J Vasc Surg. 2022;75(3):813–823.

17.

Ahmad

Mylonas

Majd

, et al. A current systematic evaluation and meta-analysis of chimney graft technology in aortic arch diseases. J Vasc Surg. 2017;66(5):1602–1610.

18.

Bosse

Kölbel

Mougin

, et al. Off-the-shelf multibranched endograft for total endovascular repair of the aortic arch. J Vasc Surg. 2020;72(3):805–811.

19.

Gouveia

Melo

Fernández Prendes

, et al. Common designs of custom-made fenestrated arch devices and applicability of an off-the-shelf design. J Endovasc Ther. 2025;32:481–489.

20.

Tish

Chase

Scoville

, et al. A systematic review of contemporary outcomes from aortic arch in situ laser fenestration during thoracic endovascular aortic repair. Ann Vasc Surg. 2023;91:266–274.

21.

McKinley

El Sayed

Panneton

. Laser fenestration in TEVAR: perspectives and future directions. Ann Vasc Surg. 2023;94:119–128.

22.

Panneton

Lin

. In situ laser fenestration for arch branch revascularization during emergent thoracic endovascular aortic repair: effective and durable. J Vasc Surg. 2018;68:E70.

23.

Reyes Valdivia

Pitoulias

, et al. Systematic review on the use of physician-modified endografts for the treatment of aortic arch diseases. Ann Vasc Surg. 2020;69:418–425.

24.

Spath

Campana

Tsilimparis

, et al. Outcomes of fenestrated and branched endografts for partial and total endovascular repair of the aortic arch—a systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2024;67(1):106–116.

25.

Chassin-Trubert

Gandet

Lounes

, et al. Double fenestrated physician-modified stent-grafts for total aortic arch repair in 50 patients. J Vasc Surg. 2021;73(6):1898–1905.

26.

Wen

, et al. Physician-modified endografts for the treatment of thoracic aortic pathologies involving the aortic arch. J Endovasc Ther. 2023;32:1426–1439.

27.

Gandet

Canaud

Ozdemir

, et al. Factors favoring retrograde aortic dissection after endovascular aortic arch repair. J Thorac Cardiovasc Surg. 2015;150(1):136–142.

28.

Luebke

Brunkwall

. Cost-effectiveness of endovascular versus open repair of acute complicated type B aortic dissections. J Vasc Surg. 2014;59(5):1247–1255.

29.

Schuster

Dorfmeister

Scheuter-Mlaker

, et al. Endovascular and conventional treatment of thoracic aortic aneurysms: a comparison of costs. Ann Thorac Surg. 2009;87(6):1801–1805.

30.

Narayan

Wong

Davies

, et al. Thoracic endovascular repair versus open surgical repair—which is the more cost-effective intervention for descending thoracic aortic pathologies. Eur J Cardiothorac Surg. 2011;40(4):869–874.