title: Radiofrequency in situ fenestration for aortic arch vessels during thoracic endovascular repair.
abstract: OBJECTIVE
  To report the first clinical application of a novel technique using radiofrequency puncture to create retrograde in situ fenestrations during thoracic endovascular aortic repair (TEVAR).
  
  
  METHODS
  Between June 2011 and December 2013, 40 TEVAR procedures were performed in our facility, including 10 cases in which in situ fenestration was planned. Two thoracic stent-graft models were deployed: the Valiant (n=5) and the Zenith TX2 (n=5). A 0.035-inch PowerWire radiofrequency guidewire delivered from a brachial approach was used to fenestrate the grafts covering a left subclavian artery (LSA) in 9 cases and a left common carotid artery in one. The fenestrations were serially dilated to 6 mm, and self-expanding Advanta V12 covered stents were positioned in the target arteries.
  
  
  RESULTS
  Technical success was achieved in 6 of the 10 planned cases. Of the remaining 4 cases, stent-grafts were deployed in zone 3 in 2 cases (one received a chimney to the LSA). Another stent-graft was deployed in zone 2 without endoleak after fenestration was abandoned (the LSA had good filling via the vertebral artery). In the last case, the fenestration was unsuccessful in double-layered (proximal extension overlap) stent-grafts; a carotid-axillary bypass was required. There were no fenestration-related complications, but overall surgical complications included a case of paraparesis that resolved following spinal drainage and a death from a preexisting aortoesophageal fistula. There were no postoperative strokes. All fenestrations remained patent, and there were no endoleaks at a mean 12-month follow-up (range 1-33).
  
  
  CONCLUSIONS
  Radiofrequency puncture is a viable alternative to needle or laser punctures for in situ fenestration during TEVAR. Early clinical results suggest technical feasibility and acceptable early outcomes.
authors.affiliation: Toronto General Hospital, University Heath Network, University of Toronto, Ontario, Canada leonard.tse@utoronto.ca.
authors.forename: Leonard W
authors.initials: LW
authors.lastname: Tse
authors.affiliation: Toronto General Hospital, University Heath Network, University of Toronto, Ontario, Canada.
authors.forename: Thomas F
authors.initials: TF
authors.lastname: Lindsay
authors.affiliation: Toronto General Hospital, University Heath Network, University of Toronto, Ontario, Canada.
authors.forename: Graham
authors.initials: G
authors.lastname: Roche-Nagle
authors.affiliation: Toronto General Hospital, University Heath Network, University of Toronto, Ontario, Canada.
authors.forename: George D
authors.initials: GD
authors.lastname: Oreopoulos
authors.affiliation: Toronto General Hospital, University Heath Network, University of Toronto, Ontario, Canada.
authors.forename: Maral
authors.initials: M
authors.lastname: Ouzounian
authors.affiliation: Toronto General Hospital, University Heath Network, University of Toronto, Ontario, Canada.
authors.forename: Kong Teng
authors.initials: KT
authors.lastname: Tan
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017545:Aortic Aneurysm, Thoracic / Q000401:mortality / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation; D017536:Carotid Artery, Common / Q000601:surgery*; D054855:Drug-Eluting Stents; D057510:Endovascular Procedures / Q000009:adverse effects / Q000379:methods; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011846:Radio Waves; D012189:Retrospective Studies; D012307:Risk Factors; D013348:Subclavian Artery / Q000601:surgery*; D016896:Treatment Outcome
keywords: aortic arch; common carotid artery; covered stent; cutting balloon; in situ fenestration; left subclavian artery; radiofrequency; self-expanding stent-graft; thoracic aneurysm; thoracic endovascular aortic repair