Re-entry catheter-guided in situ fenestration to preserve the left subclavian artery during thoracic endovascular aortic repair for subacute type B aortic dissection

Figures

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  Fig 1. Initial aortography in left anterior oblique (LAO) projection showing the dissection site and landing zone in zone 2, along with anatomical landmarks for stent deployment in the left subclavian artery.

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  Fig 2. Puncture of the outer curvature of the endograft using a BeBack 4F × 120 cm system. The nose cone of the RelayPro NBS endograft is maintained in place to provide support during puncture and facilitate device passage through the fenestration, avoiding the need for a Coda balloon in this area and preserving the endograft's conformation without deformation during force application. Red arrow indicate the exact puncture site with the BeBack system on the greater curvature of the endograft.

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  Fig 3. Confirmation of intragraft positioning in right anterior oblique (RAO) projection. Red arrows indicate the puncture site and 0.018″ guidewire passage. The same RAO projection was used before puncture to verify BeBack catheter apposition between stent struts and at the dome of the prosthesis for secure fabric perforation, emphasizing the critical role of double projection for procedural success and safety.

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  Fig 4. Sequential dilation using Armada 018 balloons, starting with 2 mm, followed by 3, 4, and 6 mm. Progressive dilation is key to avoiding fabric tears in the endograft.

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  Fig 5. Deployment of an 8 × 37 mm BeGraft stent. The stent is deployed using a pullback technique of the introducer sheath once the stent has been advanced beyond it to the target area. A safety margin of 8 mm was maintained because the endograft fabric demonstrated erratic behavior beyond 10 mm during bench testing.

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  Fig 6. Proximal flaring of the stent graft using a 9 × 20 mm Mustang balloon to ensure proper sealing and prevent migration. The maneuver is repeated distally, matching the stent 1:1 with the subclavian artery and achieving a 20-mm landing zone. The crossing zone of the endograft was respected throughout the procedure.

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  Fig 7. Final angiographic control of the in situ fenestration (ISF) site. The stent graft was positioned properly, maintaining patency of the left subclavian artery with no opacification of the false lumen.