Clinical outcomes of total endovascular aortic arch repair by in situ microneedle fenestration using the triple (stiff)-sheathed gutter technique

Purpose To investigate the outcomes of total endovascular aortic arch repair (TEAAR) via in situ micro-needle fenestration (ISMNF) with the triple (stiff)-sheathed gutter technique. Materials and methods In this retrospective study, the data of consecutive patients who underwent TEAAR via ISMNF with triple (stiff)-sheathed gutter technique between August 2022 and April 2025 were analyzed. Three 6-Fr, 90-cm sheaths were placed into ascending aorta without removing the dilator and super-stiff guidewires during main stent-graft deployment. This configuration creates a gutter between the stent-graft and aortic wall to maintain perfusion to supra-aortic branches. Operative details, technical success, 30-day and midterm outcomes, and adverse events were recorded. Kaplan–Meier analysis was used to estimate freedom from all-cause death and reintervention. Results Overall, 36 patients were included. The technical success rate was 94.4% (34/36). Endovascular reconstruction of cervical branches was successfully performed in all cases. The 30-day mortality was 2.8%. The median follow-up period was 19 months (range, 1–32 months). The all-cause death rate was 11.1% (4/36), with no cases of any aorta-related death. The prevalence of endoleaks during follow-up was 13.9% (5/36). The overall stroke rate was 8.3% (3/36). The 1- and 2-year survival rates were 97.3% ± 2.7% and 85.8% ± 8.1%, respectively. The cumulative rate of freedom from reintervention at 1 and 2 years was 87.5% ± 5.9% and 83.2% ± 7.0%, respectively. Conclusion TEAAR via ISMNF with the triple (stiff)-sheathed gutter technique was performed with a 94% technical success rate and stroke risk similar to open surgery.