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

Figures

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  Figure 1. A, B. Pre-operative computed tomography angiography showing an aortic arch dissection aneurysm with an isolated left vertebral artery (ILVA), which arose from the top of the aortic arch with a diverticular orifice. C. Intra-operative angiography confirmed the aortic arch dissection aneurysm with an ILVA. D. A covered stent graft was deployed in the aortic arch covering the primary tear of the dissection, ILVA, and left subclavian artery.

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  Figure 2. A, B. A 6F steerable sheath (white arrow) was placed in the left subclavian artery through brachial access to perform the angiography to display the isolated left vertebral artery (ILVA) ostium. Another 6F long sheath with an adjustable puncture needle (black arrow) was introduced into the aortic arch through the right femoral access and placed against the ILVA ostium confirmed in different projection angles. C. Antegrade in situ fenestration was performed using a needle followed by advancing a 0.018 inch guidewire via the puncture hole into the ILVA. D. The location of the guidewire in the ILVA was confirmed with angiography through the left subclavian artery.

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  Figure 3. A. Completion angiography showing successful exclusion of aortic dissection and patent isolated left vertebral artery (ILVA) and left subclavian artery (LSA). B, C. Post-operative one year follow up imaging showing patent ILVA and LSA and favourable aortic remodelling.