PMC10394511_01
(A) Preoperative image. The computed tomography image shows an enlarged aortic arch with a maximal diameter of 7 cm. (B) Post-operative image. There was no endoleak detected, the aneurysmal sac are thrombosed and the fenestrated graft to the neck vessels are patent.
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F1
TAR with the FET procedure was performed using the open in-situ fenestration technique (Supplementary Video S1) on a 78-year-old woman who was diagnosed with a 7-cm thoracic aortic aneurysm incidentally detected during a medical examination (Figure 1). Subsequent computed tomography angiography revealed a good arch morphology without endoleaks (Figures 1B and 4).
Procedures of total arch replacement with open in-situ fenestration. (A) Proximal anastomosis: The ascending aorta is anastomosed with a vascular graft. (B) BCA anastomosis: The BCA is clamped and anastomosed with the side arm of the vascular graft. (C) Main stent graft deployment: With direct vision, an endovascular stent graft (cTAG) is inserted into the arch. (D,E) Open in-situ fenestration: Both the LSCA and LCCA are fixed with covered stents by in-situ fenestration. After fenestration, the stent graft is guided by a wire for insertion and secured to both arteries. (F) Distal anastomosis: The proximal stent-free side of the cTAG is anastomosed with the aortic wall and distal end of the vascular graft. BCA, brachiocephalic artery; LSCA, left subclavian artery; LCCA, left common carotid artery.
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F2
Teflon felt strips were secured outside the suture line (Figure 2A). Second, the brachiocephalic artery (BCA) was sewn with the branch of the graft, creating a stump on the proximal side of the BCA (Figure 2B). Gore & Associates, Inc., Newark, DE, USA] was delivered antegrade from Zone 0 to the distal arch and descending aorta (Figure 2C). After stent graft placement, the open in-situ fenestration technique was sequentially applied to the LSCA (Figure 2D) and LCCA (Figure 2E). Lastly, the proximal stent-free side of the primary stent graft was anastomosed with the aortic wall and distal end of the graft with four branches during antegrade cerebral perfusion (18 C, 10 ml/kg/min) through the cervical stent grafts (Figure 2F).
Balloon dilatation to secure the endografts with fenestration. The LCCA and LCCA endografts (VIABAHN) undergo balloon dilation to obtain fenestration and good fixation. LSCA, left subclavian artery; LCCA, left common carotid artery.
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F3
Balloon dilatation was then performed to ensure patency and fixation of the branch stent graft to prevent endoleaks through the junction (Figure 3).
Postoperative reconstruction image. Postoperative computed tomography demonstrates adequate fixation of the main stent and two in-situ fenestration stents in the left common carotid and left subclavian arteries. The aneurysm sac was excluded from the analysis.
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F4
Subsequent computed tomography angiography revealed a good arch morphology without endoleaks (Figures 1B and 4).