Single-center Experience And Systematic Review Of Fenestrating Technique In The Treatment Of Thoracic Aortic Disease

Part Ⅰ Single-Center Experience of Fenestration Technique in the Treatment of Thoracic Aortic Disease Objective:Revascularization of the supra-aortic major branches by thoracic endovascular aortic repair(TEVAR)is challenging owing to the complex and varied anatomy.The clinical experience of fenestration in the treatment of thoracic aortic diseases in our hospital was summarized,and the curative effects of in situ fenestration(ISF)and preprocedural fenestration(PF)were compared.Materials and Methods:The clinical data of 42 patients with thoracic aortic disease who underwent fenestration to reconstruct the important branches of the arch in our hospital from July2017 to December 2020 were analyzed retrospectively.Demographic information,clinical manifestations,perioperative complications and short-term follow-up results were analyzed.In 28 cases,in situ fenestration technique was used,including left subclavian artery in 14 cases,left subclavian artery and left common carotid artery in 6 cases,left common carotid artery and innominate artery in 1 case,three branches of supra-arch in 6 cases,and right subclavian artery in 1 case.Pre-fenestration technique was used in the other 14 cases,including fenestration of left subclavian artery in 7 cases,left subclavian artery and left common carotid artery in 3cases,three branches of supra-arch in 2 cases,right subclavian artery in 1 case.At the same time,the right subclavian artery and superior mesenteric artery were fenestrated in1 case.Results:TEVAR was performed in all patients.The total success rate was 95.7%(67/70),and the 30-day mortality rate was 4.8%(2/42).There were 35 males and 7 females with an average age of(62.0±11.5)years.Lesion types including 16 cases of thoracic aortic aneurysms(38.1%,16/42),blunt traumatic aortic injury in 2 cases(including aortic dissection or aneurysm)(4.8%,2/42),penetrating ulcer or intermural hematoma in 4cases(9.5%,4/42),Stanford type B dissection in 15 cases(35.7%,15/42)and Stanford type A dissection in 5 cases(including after artificial vascular replacement)(11.9%,5/42).ISF group compared PF group,incidence of cerebral infarction were 10.7% and0% respectively(P = 0.525),the incidence of respiratory failure were 10.7% and 0%respectively(P = 0.525),the incidence of acute coronary syndrome were 7.1% and 0%respectively(P = 0.545),the new incidence of aortic dissection were 3.6% and 0%respectively(P > 0.999),the transient incidence of arrhythmia were 10.7% and 0%respectively(P = 0.525),the transient incidence of nerve dysfunction were 7.1% and7.1% respectively(P > 0.999),The incidence of type I endoleak was 0% and 7.1%(P=0.333),and the incidence of type III endoleak was 10.7% and 0%(P=0.525),respectively.During the total follow-up period of 16.2 ±13.1 months,the average follow-up time was 15.6 ±13.6 months in ISF group and 17.2 ±12.5 months in PF group.The blood flow of the re-vascularized vessels was unobstructed,the shape and position of the metal stent were good,there was no obvious shifting or new endoleak,and the false lumen thrombus was found in some patients with aortic dissection.Part Ⅱ Systematic Review and Meta-Analysis of In Situ Fenestration and Pre-Fenestration in the Treatment of Thoracic Aortic Diseases Objective:To systematically evaluate the safety and efficacy of in situ fenestration and pre-fenestration in the treatment of thoracic aortic diseases.Materials and Methods:Pubmed,Embase,Cochrane,Web of Science,China National Knowledge Infrastructure,Wanfang data,VIP data and China Biology Medicine disc were searched,and the relevant data of in situ fenestration and pre-fenestration in the treatment of thoracic aortic diseases were collected.Until September 2020,the research characteristics were included according to PRISMA statement,Minors scale was used to evaluate the quality of the literature,and R4.0.3 software was used for Meta analysis.Results:A total of 24 articles were included.906 patients with thoracic aortic disease were treated with in situ fenestration or pre-fenestration.There were 402 cases of in situ fenestration and 504 cases of pre-fenestration.ISF group compared PF group,the technical success rate was 96.7% and 96.7%(P=0.963),the 30 d mortality rate was 1.7%and 1.8%(P=0.960),the type I endoleak rate was 1.5% and 2.6%(P=0.257),the type II endoleak rate was 0.7% and 1.4%(P=0.549),the type III endoleak rate was 0.7% and0.2%(P=0.465),the vascular restenosis or occlusion rate was 2.3% and 1.2%(P=0.140),and the reintervention rate was 1.5% and 4.4%(P=0.013).After excluding heterogeneity,the technical success rate was 96.7% vs 98.0%(P=0.166),and the re-intervention rate was 1.5% vs 3.3%(P= 0.09).Conclusion:In situ fenestration technique and pre-fenestration technique are safe and effective measures for the treatment of thoracic aortic diseases.Multicenter,large sample,medium and long-term follow-up is needed to further support the results of this study.