An international multi-center application of self-radiopaque markers guiding physician-modified fenestration (S-fenestration) in endovascular repair of aortic arch pathologies

Thoracic endovascular aortic repair (TEVAR) has currently become the “first-line choice” for the repair of various descending aorta pathologies. However, for aortic arch pathologies, physician-modified fenestration TEVAR is an alternative method that is capable of dealing with some of the anatomic difficulties in this special case. In this article we introduce a well-established technique that uses a radiopaque marker in the stent graft, self-radiopaque physician-modified fenestration (SF). We analyzed a cohort of retrospective and follow-up data from 7 hospitals all over the world for patients who underwent SF-TEVAR. To our knowledge, this study holds the largest group size ever around the worldi. The data of 658 patients who underwent SF TEVAR from 6 different countries and 7 hospitals from December 2015 to May 2023 were retrospectively analyzed. Information regarding procedure time, contrast dose stent graft, and bridging stent was collected for analysis, and follow-up results were recorded at 1 month, 6 months, 12 months after the procedure, analyzed the survival rate and branch patent rate. We found an instant maneuver success rate (with successful fenestration in TEVAR) of 98.8 %. There were 696 aortic stent grafts implanted and 726 bridging stents among all the patients. The operation time was 85.8 ± 35.3 min, and the contrast dosedose was 85.2 ± 22.0 ml. Eight bailout stent grafts were implanted into the LSA using the chimney technique (1.2 %), and three cases of fenestration were successfully corrected after misalignment (0.5 %). Large fenestration for the IA, LCCA, and LSA simultaneously was successful in 5 patients (0.8 %). In addition, There were 15 cases (2.3 %) that used SF combined with other techniques (in-situ fenestration, chimney, snorkel, or bypass methods) according to the “HENDO” consensus in China. The peri-operative mortality was 0.5 % (within 30 days of SF-TEVAR procedures). Endoleak was observed in 53 patients (8.1 %) immediately after procedure DSA and in 47 patients (7.1 %) beyond 30 days after the procedure during follow-up. In the 90 months of follow-up data, the overall survival rate was 96.5 %, with a branch artery patent rate of 98.8 %. The well-established SF method that uses radiopaque markers in aortic stent graft to guide physician-modified fenestration in TEVAR is a safe and effective procedure that leads to durable long-term results. Moreover, the survival rate and branch patent rate are both acceptable. This SF-TEVAR is thus a viable alternative method to keep branch arteries patent in cases of aortic arch pathologies.