Analysis Of Early And Mid-term Results Of In Situ Pinhole Fenestration In The Treatment Of Complex Aortic Arch Diseases In TEVAR

Objective: To investigate the early and mid-term results and technical details of the treatment of complex aortic arch diseases by fenestration of the central pinhole in the thoracic aortic endovascular repair(TEVAR).Methods: From January 2017 to December 2018,25 patients with thoracic aortic disease who underwent in situ pinhole fenestration in cardiovascular surgery of Affiliated Hospital of Qingdao University were analyzed retrospectively.Among them,there were 17 males and 8 females,with an average age of 55.8 ± 7.8 years;11 cases of type B aortic dissection,7 cases of aortic aneurysm,3 cases of retrograde type A aortic dissection and 4 cases of aortic ulcer were diagnosed in Hospital;14 cases of chest and back pain,2 cases of abdominal pain,1 case of hoarseness,1 case of shoulder pain,and 7 cases of no obvious symptoms,but For other reasons,CTA was performed to diagnose thoracic aortic disease,hypertension in 19 cases,diabetes in 4 cases,old cerebral infarction in 3 cases,coronary heart disease in 3 cases,renal insufficiency in 1 case,and smoking in 15 cases.All patients were followed up for 12-36 months,with a median follow-up of 21 months.The clinical data and follow-up results were analyzed.Results: The success rate of window opening was 95.0%(38 / 40).Of the 25 patients,15 underwent left subclavian artery fenestration,and 13 achieved technical success.One patient had pseudoaneurysm.The pseudoaneurysm compressed LSA and resulted in stenosis,which made the catheter unable to pass through the LSA lesion and failed to open the window.In another patient,the LSA was seriously distorted,and the catheter of the balloon puncture system could not reach the ideal position through LSA,and the window could not be opened successfully.The fenestration of the left subclavian artery and the left common carotid artery was completed in 5 cases,and the fenestration of the three branches of the aortic arch was successful in 5 cases.When the window is opened three times,it needs to be carried out under the condition of temporary flow protection of cerebral blood supply of femoral carotid artery.One case had external iliac artery dissection and one case had cerebrovascular event.During a median follow-up of 21 months,one patient developed a retrograde type A dissection,and then underwent BCT fenestration after the aortic stent graft was implanted again to cover BCT.One case showed numbness of the left fingertip,CT angiography(CTA)showed stent stenosis in LSA,and CTA showed no aneurysm leakage or dilatation.Conclusion: Through the analysis of follow-up results,good early and mid-term results have been achieved in the operation of needle hole in situ fenestration of the superior branch of the aortic arch,which is technically feasible.But before this technology is widely used,further research is needed to determine the long-term effect.Significance: The selection of complex aortic arch repair includes pre opening window,in situ opening window and chimney technology.The specific challenges of arch endovascular repair are related to their potential nervous system complications,anatomical angle of branch artery,large blood flow,aortic pulsation,status of aortic valve,etc.Compared with the long-term custom-made stent,the in-situ windowing technology is not limited by the instrument and has more advantages in emergency.In situ pinhole fenestration of aortic arch covered stent is technically feasible and has achieved acceptable early and mid-term results in selected patients.In situ fenestration technology in the premise of ensuring good treatment results also continues its advantages of minimally invasive,and will benefit more patients with high-risk aortic disease in the future.