TEVAR combined with laser in-situ fenestration in the treatment of

type A aortic dissection

Department of Vascular Surgery

Ninth People’s Hospital

Shanghai Jiao Tong University School of Medicine

Xiaobing Liu，Xinwu Lu

Disclosure

Speaker name:

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I have the following potential conflicts of interest to report:

Consulting

Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company

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I do not have any potential conflict of interest

Although TEVAR in descending aortic pathology, such as type B dissection, has shown promising early and midterm results, it remains a challenge in type A aortic dissection.

Endovascular Treatment for type A dissection

Figures-Rutherford's Vascular Surgery 8

Murphy EH, Dimaio JM, Dean W, Jessen ME, Arko FR. Endovascular repair of acute traumatic thoracic aortic transection with laser-assisted in-situ

fenestration of a stent-graft covering the left subclavian artery. Journal of endovascular therapy : an official journal of the International Society of

Endovascular Specialists. 2009;16:457-463

In vitro laser fenestration on stent grafts

In our center

A diode laser，previously used for ablation of saphenous veins

Preliminary results

7

Challenge for type A aortic dissection with laser in-situ fenestration

1. Accurate deployment of ascending aortic

stent graft

2. Brain protection during procedure

3. Reconstruct all of the aortic arch

branches

• 58 patients （from April 2014 to May 2018）, Stanford type

A aortic dissection who received TEVAR combined with in situ

laser fenestration from zone 0 landing were retrospectively

analyzed.

• Critical inclusion criteria, including the damage to the aortic

branches and intimal tears adjacent to the aortic/coronary

valves or the proximal seal zone more than 15 mm.

• Exclusion criteria included the following:

(1) patients with cardiopulmonary and renal insufficiency

not tolerant to general anesthesia;

(2) less than 15 mm distance (seal zone) between intimal

tears and ostia of coronary artery;

(3) Coronary ostia or cardiac vavles affected by the

dissection.

Retrospective study in our center

In situ venous laser fenestration of the LCA, innominate artery, and

LSA during TEVAR.

Procedures in brief

• Procedural success rate 91.38% (53 of 58 ).

• Two LSA fenestration was abandoned due to the highly

tortuous LSA, with an acute angle between its origin and

the aorta arch.

• Two fenestrations were not achieved due to an acute

takeoff of innominate artery in type III aortic arch in early

time.

• One patient died of pericardial tamponade during operation

• In-hospital mortality rate 3.45%

• one due to severe pneumonia after operation

• stroke occurring in two patient (3.45%)

• no myocardial infarction, transient ischemic attacks,

cerebral infarction, respiratory system, renal system, or

other neurologic complications occurred during the follow-

up period.

• A follow-up CTA (10.6 ± 5.4 months) indicated that

• One type Ia endoleaek and one type II endoleak

Results

One cerebral infarction might have been caused by

balloon burst due to oversized inflations during PTA

Typical case 1：

Female，47 years old，sudden chest back pain for 6h

Extracorporeal bypass for cerebral protection：

Step 1: the 16F sheath was inserted into the ascending aorta until next to the coronary valve (15 mm above).

16F Sheath

6F Sheath

12F Sheath

Schematic illustration of the cerebral circulation protection with an extracorporeal bypass.

Accurate deployment of ascending aortic stent graft

(cTAG, Gore, as the first choice for the flexibility)

Reconstruction of LCA with laser in-situ fenestration

Fluency 8*40mm, BARD Mustang 8*60mm, BOSTON

Reconstruction of LCA with laser in-situ fenestration

Extracorporeal bypass adjustment after LCA reconstruction

16F Sheath

6F Sheath

12F Sheath

Dorado 10*40mm, BARD Fluency 13.5*40mm, BARD

Reconstruction of the innominate artery with laser in-situ fenestration

Reconstruction of LSA with laser in-situ fenestration

Final angiography

Completion angiography

Issues：one or two fenestrated channels？

Typical case 2: horns arch in short common segment

First of all, open the

LCA and the INA one

by one， and try to

deviate from the two

opening points.

LSA in last step

Horns arch in short common segment

Horns arch

Follow up CTA in day 3

All kinds of difficulties in one patient！！！

Follow-up CTA 1 week post Op.

Follow-up CTA 1 week post Op.

3 weeks after Op.

The advantages of the diode laser in-situ fenestration

• Wavelengths of 940 or 810 nm, with selective tertiary hemoglobin peak and

a 0.3-mm penetrated depth in the blood, less damages to the vessles

• The energy generated by this diode laser was absorbed by water and

hemoglobin to avoid bubbles, which might cause stroke during fenestration

for carotid arteries.

• Using 18 W laser energy, which might destroy and soften the PTFE or

Dacron fabrics thoroughly, creating a round and intact fenestration .

• The soft laser fiber could pass through complex and tortuous aortic arch

anatomic variations.

Conclusions

• In situ venous laser fenestration to revascularize the supra-aortic branches

is a feasible and effective option during TEVAR for Stanford type A aortic

dissection.

• Venous laser fenestration under cerebral circulation protection with an

extracorporeal bypass presents with lower-fenestration-related

neurovascular complications.

• The high technical success, low mortality, and high patency have

extended this application to more patients.

• Further studies with prolonged follow-up, increased surgical amount,

prospective basic research of fluid mechanics change, and aortic

remodeling after TEVAR are required.

THANKS FOR YOUR ATTENTION!

•Department of Vascular Surgery

•Ninth People’s Hospital

•Shanghai Jiao Tong University School of Medicine

TEVAR combined with laser in-situ fenestration in the treatment of

type A aortic dissection

Department of Vascular Surgery

Ninth People’s Hospital

Shanghai Jiao Tong University School of Medicine

Xiaobing Liu，Xinwu Lu