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.