P125. Endovascular Laser Fenestration of a Frozen Elephant Trunk Stent Graft for Treatment of Chronic Cerebral Malperfusion
Presented During: POD Abstracts (Available for viewing in the exhibit hall for the duration of the meeting)
Medical University of South Carolina
Charleston, SC
United States - Contact Me
Richard Shi is a current second year integrated vascular surgery resident at the Medical University of South Carolina. He graduated with a B.S. degree in biomedical medical engineering at the Johns Hopkins University and subsequently received his M.D degree from New York Medical College in Valhalla New York. His academic interests are in device development, entrepreneurship, peripheral vascular disease, and aortic disease.
Thursday, April 25, 2024: 5:38 PM - 7:00 PM
Sheraton Times Square
Room: Central Park
Description
Objectives
The Frozen Elephant Trunk (FET) can be used to treat acute type A aortic dissections and is described in conjunction with a hemiarch repair. However, inadvertent placement or maldeployment of elephant trunk can have severe patient complications. We describe a case of a FET placed across the origins of the arch vessels during hemiarch repair for dissection at a referring hospital. This was revised through laser fenestration and stenting to restore adequate flow to the left subclavian (SCA) and left common carotid artery (CCA).
Methods
A 69-year-old man with history of acute TAAD in 2018, status post hemiarch repair with frozen elephant trunk (FET) across his great vessels, presented with progressive dizziness and syncope. A computed tomography scan revealed stent graft coverage of the brachiocephalic, L CCA, and L SCA, with retrograde flow through a false lumen fed by a fenestration of the dissection flap near aortic bifurcation. He had reverse coarctation physiology, with lower extremity blood pressures at 200s/90s, and upper extremity blood pressures at 130s/60s. He was unable to tolerate anti-hypertensives due to cerebral hypoperfusion. Carotid duplex demonstrated flow reversal in the left internal carotid and bilateral vertebral arteries. Given lifestyle limiting symptoms and an elevated peri-operative death/stroke risk with a redo open arch repair, we performed an endovascular intervention via in-situ laser fenestration of his FET with L CCA and L SCA stenting.
Results
An initial aortogram revealed the stent graft was covering the great vessels, which were supplied only through false lumen flow (fig 1a). A 7 French sheath was placed into the left radial artery and a laser atherectomy catheter was inserted into the left SCA origin, but fenestration attempts were unsuccessful. Thus, we placed a steerable sheath via right femoral access into graft, and laser fenestrated through the graft into the false lumen near the left SCA origin. A wire was advanced into both the left SCA and left CCA, followed by kissing balloon dilation. Using the Culotte technique, balloon expandable bare-metal stents was placed in the L CCA and L SCA through the fenestration (fig 1b). Post-operatively, blood pressure in his left arm and legs equalized, his dizziness resolved, and he was able to maintain normotension without symptoms. His stents remain open several months after his procedure.
Conclusion
We present a novel case report where laser fenestration is used to salvage a misplaced FET. Laser fenestration is frequently used at our institution in complex endovascular aortic aneurysm repair and can be a minimally invasive alternative for salvaging FET deployed across the arch.
Authors
Richard Shi (1), Sanford Zeigler (1), Mathew Wooster (1)
Institutions
(1) Medical University of South Carolina, Charleston, SC
The Frozen Elephant Trunk (FET) can be used to treat acute type A aortic dissections and is described in conjunction with a hemiarch repair. However, inadvertent placement or maldeployment of elephant trunk can have severe patient complications. We describe a case of a FET placed across the origins of the arch vessels during hemiarch repair for dissection at a referring hospital. This was revised through laser fenestration and stenting to restore adequate flow to the left subclavian (SCA) and left common carotid artery (CCA).
Methods
A 69-year-old man with history of acute TAAD in 2018, status post hemiarch repair with frozen elephant trunk (FET) across his great vessels, presented with progressive dizziness and syncope. A computed tomography scan revealed stent graft coverage of the brachiocephalic, L CCA, and L SCA, with retrograde flow through a false lumen fed by a fenestration of the dissection flap near aortic bifurcation. He had reverse coarctation physiology, with lower extremity blood pressures at 200s/90s, and upper extremity blood pressures at 130s/60s. He was unable to tolerate anti-hypertensives due to cerebral hypoperfusion. Carotid duplex demonstrated flow reversal in the left internal carotid and bilateral vertebral arteries. Given lifestyle limiting symptoms and an elevated peri-operative death/stroke risk with a redo open arch repair, we performed an endovascular intervention via in-situ laser fenestration of his FET with L CCA and L SCA stenting.
Results
An initial aortogram revealed the stent graft was covering the great vessels, which were supplied only through false lumen flow (fig 1a). A 7 French sheath was placed into the left radial artery and a laser atherectomy catheter was inserted into the left SCA origin, but fenestration attempts were unsuccessful. Thus, we placed a steerable sheath via right femoral access into graft, and laser fenestrated through the graft into the false lumen near the left SCA origin. A wire was advanced into both the left SCA and left CCA, followed by kissing balloon dilation. Using the Culotte technique, balloon expandable bare-metal stents was placed in the L CCA and L SCA through the fenestration (fig 1b). Post-operatively, blood pressure in his left arm and legs equalized, his dizziness resolved, and he was able to maintain normotension without symptoms. His stents remain open several months after his procedure.
Conclusion
We present a novel case report where laser fenestration is used to salvage a misplaced FET. Laser fenestration is frequently used at our institution in complex endovascular aortic aneurysm repair and can be a minimally invasive alternative for salvaging FET deployed across the arch.
Authors
Richard Shi (1), Sanford Zeigler (1), Mathew Wooster (1)
Institutions
(1) Medical University of South Carolina, Charleston, SC
Presentation Duration
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