title: In situ laser fenestration for revascularization of the left subclavian artery during emergent thoracic endovascular aortic repair.
abstract: OBJECTIVE
  To present midterm outcomes of thoracic endovascular aortic repair (TEVAR) with laser fenestration to revascularize the left subclavian artery (LSA) as an alternative to debranching.
  
  
  METHODS
  Six symptomatic patients (3 men; mean age of 50 years) underwent emergent TEVAR with LSA revascularization via laser graft fenestration. Three patients had large thoracic aortic aneurysms (2 secondary to chronic dissection); 1 patient had an acute symptomatic type B aortic dissection, and 2 patients had intramural hematomas. Emergent TEVAR was carried out with deployment of a Dacron endograft over the orifice of the left LSA. Through retrograde brachial access, a 0.018-inch wire was placed at the ostium of the LSA followed by laser catheter fenestration of the graft. A 10-mm covered stent was deployed through the fenestration to traverse the endograft and LSA; the endograft portion of the covered stent was flared.
  
  
  RESULTS
  Laser fenestration was successful in 5 of 6 attempts; 1 fenestration was abandoned secondary to an acute LSA takeoff in a type III aortic arch. In this case, the stent was placed as a snorkel to successfully revascularize the LSA with no adverse consequences. There were no fenestration-related complications and no neurological morbidity. At a mean 8-month follow-up (range 1-17), no patients had died, and all LSA stents were patent, with no fenestration-related endoleaks on imaging.
  
  
  CONCLUSIONS
  In situ retrograde laser fenestration is a feasible and effective option for revascularizing the LSA during emergent TEVAR. Longer follow-up is necessary to determine the durability of this technique.
authors.affiliation: Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, Virginia 23570, USA.
authors.forename: Sadaf S
authors.initials: SS
authors.lastname: Ahanchi
authors.forename: Babatunde
authors.initials: B
authors.lastname: Almaroof
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Stout
authors.forename: Jean M
authors.initials: JM
authors.lastname: Panneton
mesh_terms: D000784:Aortic Dissection / Q000000981:diagnostic imaging / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation*; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation*; D005260:Female; D006406:Hematoma / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D007834:Lasers; D008297:Male; D008875:Middle Aged; D011474:Prosthesis Design; D012189:Retrospective Studies; D015607:Stents; D013348:Subclavian Artery / Q000000981:diagnostic imaging / Q000601:surgery*; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014768:Virginia