Endovascular laser fenestration of a frozen elephant trunk stent graft for treatment of chronic cerebral malperfusion.

Objectives: Mal-deployment of the thoracic endovascular aortic repair (TEVAR) stent graft during a frozen elephant trunk (FET) procedure for an acute type A aortic dissection (ATAAD) leads to devastating complications. We report a hemiarch replacement with TEVAR stent graft covering the aortic arch vessels salvaged through an endovascular approach.

Methods: A 69-year-old man with ATAAD in 2018, status post-hemiarch repair with TEVAR, presented in 2023 with progressive dizziness/syncope and lower extremity hypertension with inability to tolerate anti-hypertensives. A CT scan revealed TEVAR stent graft coverage of the brachiocephalic, left common carotid (LCA), and left subclavian artery (LSA), with retrograde flow into the arch vessels through a false lumen fed by a dissection fenestration at the aortic bifurcation. Given an elevated peri-operative death and stroke risk with an open arch revision, we performed an in situ anterograde laser fenestration of his FET with LCA and LSA stenting via the Culotte technique.

Results: On 1 year follow-up, the patient's dizziness has resolved, and he has maintained normotension via anti-hypertensives.

Conclusion: Laser fenestration and the Culotte technique can be used to salvage a TEVAR causing coverage of the arch vessels, showing that endovascular techniques can be a safe alternative for rescuing mal-positioned FETs.