Antegrade In Situ Fenestration During Thoracic Endovascular Aortic Repair for Preserving Isolated Left Vertebral Artery

Abstract

Introduction

An isolated left vertebral artery (ILVA) on the aortic arch with aortic arch pathologies is common, but how to preserve the ILVA blood flow during endovascular repair remains challenging. Several strategies have been reported but there is still no consensus on the best treatment. This case report presents a novel totally endovascular technique for ILVA revascularisation using antegrade in situ needle assisted fenestration without neck surgical procedures.

Report

A 72 year old man with an ILVA and an incomplete circle of Willis underwent endovascular repair of an aortic arch dissection aneurysm. A 30–26 x 160 mm polytetrafluoroethylene aortic stent graft (Ankura; Lifetech, Shenzhen, China) was deployed proximally in zone 2 of the aortic arch covering the primary tear together with the ILVA and left subclavian artery (LSA). A 6F steerable sheath was placed in the LSA through brachial access, and another 6F long sheath with an adjustable puncture needle was introduced through the right femoral access and placed against the ILVA ostium with the guidance of LSA angiography. Antegrade ILVA fenestration was successfully performed using a needle, and a 0.018 inch guidewire was introduced through the puncture hole, followed by balloon dilation and implantation of a 4.5 × 12 mm balloon expandable bare stent (Dynamic; Biotronik, Bulach, Switzerland). The LSA was reconstructed using a retrograde in situ needle fenestration technique through the steerable sheath from left brachial access, and a 9 × 50 mm Viabahn stent graft was deployed. Post-operatively, the patient recovered uneventfully without neurological deficit. One year follow up imaging confirmed patent ILVA and LSA, and favourable aortic remodelling without any leakage.

Conclusion

This case suggests that the totally endovascular technique of antegrade in situ fenestration is feasible and effective for preserving an ILVA.