In Situ Fenestration–Assisted TEVAR in Patients With Complex Pathology Involving the Aortic Arch

Purpose: To assess the feasibility, safety, and short-term clinical outcomes of in situ fenestration during thoracic endovascular aortic repair (ISF-TEVAR) employing an electrocautery-connected guidewire combined with a novel, pump-less, extracorporeal femoro-carotid bypass for cerebral perfusion in patients with complex aortic arch pathology. Materials and Methods: This prospective, single-center study included 19 consecutive patients treated between February 2024 and September 2025. A homemade extracorporeal arterio-arterial bypass was constructed using femoral arterial inflow and intra-aortic balloon pump (IABP) tubing connected to supra-aortic sheaths to maintain continuous cerebral perfusion during fenestration. Fenestrations were performed with an electrocautery-connected 0.018-inch chronic total occlusion-dedicated guidewire. Patients’ demographics, procedural details, perioperative outcomes, and early follow-up data were analyzed, with stratification according to the number of fenestrated supra-aortic branches. Results: A total of 37 supra-aortic branches were targeted: 3-branch fenestrations in 6 patients (31.6%), 2-branch in 6 patients (31.6%), and single-branch in 7 patients (36.8%). Technical success, defined as successful graft fenestration with patent branches on completion angiography, was achieved in 94.5% (35/37). One failed innominate artery fenestration was managed with chimney-assisted TEVAR, and 1 left subclavian artery fenestration was successfully completed in a subsequent procedure. Operative time increased with procedural complexity (140 ± 12 minutes for 1 branch, 152 ± 10 minutes for 2 branches, and 162 ± 13 minutes for 3 branches; P = .004). No intraprocedural mortality occurred. Two perioperative strokes (10.5%) and 2 in-hospital deaths (10.5%) were recorded, 1 death was due to vertebrobasilar stroke and the other due to retrograde type A aortic dissection with rupture. Median hospital stay was 8 days. During a mean follow-up of 9.2 months, there was no aorta-related mortality, with an overall survival rate of 89.5%. All stented branches remained patent, and 2 endoleaks (10.5%) were successfully treated endovascularly. Conclusion: In situ fenestration during thoracic endovascular aortic repair using an electrocautery-connected wire combined with a temporary, pressure gradient-driven extracorporeal femoro-carotid bypass is a feasible, reproducible, and safe technique for complex aortic arch repair. This fully percutaneous approach ensures continuous cerebral perfusion, demonstrates efficient procedural metrics, and yields favorable short-term outcomes, representing a practical alternative when custom-made devices or hybrid surgical procedures are not available. Clinical Impact In situ fenestration–assisted TEVAR combined with a temporary pumpless extracorporeal femoral–carotid bypass enables continuous cerebral perfusion during complex aortic arch interventions without the need for cardiopulmonary bypass or surgical debranching. This technique expands the feasibility of fully endovascular multibranch arch repair in urgent or anatomically challenging cases where custom-made devices are unavailable. For clinicians, this approach offers a practical and reproducible strategy to mitigate cerebral ischemic risk while maintaining procedural efficiency and percutaneous access. This technique may facilitate broader adoption of in situ fenestration by providing a cerebral protection strategy using readily available endovascular equipment.