Endovascular Repair of Acute Traumatic Thoracic Aortic Transection with Laser-Assisted In-Situ Fenestration of a Stent-Graft Covering the Left Subclavian Artery

Purpose: To report the use of in-situ laser-assisted endograft fenestration during thoracic endovascular aortic repair (TEVAR). Case Report: A healthy 26-year-old man presented to the emergency department after sustaining blunt chest trauma. He was hemodynamically stable, although he subjectively complained of tearing chest pain and pleuritic chest wall pain. Radiography revealed a left clavicular fracture, multiple rib fractures, and a widened mediastinum. Imaging showed a partially contained acute aortic transection just distal to the takeoff of the left subclavian artery (LSA); the arch had a bovine configuration, with a shared origin of the right innominate and left common carotid arteries. Endovascular repair was elected, but to avoid sacrificing the LSA, TEVAR with in-situ graft fenestration was performed to reduce the risk of posterior circulation stroke, spinal cord ischemia, and subclavian steal syndrome. A Talent thoracic stent-graft was deployed, with the covered portion of the endograft extending just distal to the shared origin of the innominate and left carotid arteries. A laser catheter was advanced through the LSA to fenestrate the endograft; the fenestration was dilated and stented with an iCast stent, which was flared proximally and distally to effect a seal. At 6 weeks, imaging documented that the repair was patent and secure; the patient continues to do well at his most recent follow-up at 8 months. Conclusion: This technique may provide a means for extending thoracic endografting technology to a greater number of patients with acute thoracic aortic pathology.