case_images: PMC10394511_01
case_images: (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.
case_images: fsurg-10-1224013-g001.jpg
case_images: PMC10394511_01_fsurg-10-1224013-g001.jpg
case_images: F1
case_images: 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).
case_images: 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.
case_images: fsurg-10-1224013-g002.jpg
case_images: PMC10394511_01_fsurg-10-1224013-g002.jpg
case_images: F2
case_images: 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).
case_images: 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.
case_images: fsurg-10-1224013-g003.jpg
case_images: PMC10394511_01_fsurg-10-1224013-g003.jpg
case_images: F3
case_images: Balloon dilatation was then performed to ensure patency and fixation of the branch stent graft to prevent endoleaks through the junction (Figure 3).
case_images: 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.
case_images: fsurg-10-1224013-g004.jpg
case_images: PMC10394511_01_fsurg-10-1224013-g004.jpg
case_images: F4
case_images: Subsequent computed tomography angiography revealed a good arch morphology without endoleaks (Figures 1B and 4).