Short-Term Follow-up of Endovascular Electrocautery Septostomy and Fenestration for Distal Landing Zone Optimization in Chronic Distal Aortic Dissections

Endovascular repair of postdissection thoracic aneurysms remains challenging due to false lumen perfusion. Landing the endograft into the true lumen renders the repair prone to false lumen perfusion through fenestrations beyond to the distal landing zone. Fenstration of the septum creating a single lumen at the distal landing zone is one possible strategy to eliminate false lumen perfusion. We describe our experience with endovascular electrocautery septostomy and fenestration. Patients with chronic distal aortic dissection who underwent endovascular electrocautery septostomy and fenestration followed by thoracic endovascular aneurysm repair were reviewed. The dissections were either a chronic type B dissection or a chronic residual type A dissection after proximal repair. Patient demographics, history, aortic characteristics, operative, and postoperative variables were collected. Between 2019 and 2022, 13 patients underwent thoracic endovascular aneurysm repair with endovascular electrocautery fenestration of the distal dissection flap to facilitate the distal seal. The average age was 60 years and 11 (85%) were men. The descending thoracic aneurysm was secondary to chronic residual dissection after prior type A repair in 11 (85%) and chronic type B dissections in 2 (15%). Median time from the initial dissection was 3.6 years. Initial technical success was achieved in 12 of 13 cases (Figures 1 and 2). Average fluoroscopy time was 57.5 minutes. One patient had a persistent type Ib endoleak after the graft failed to fully expand, despite fenestration, and underwent coiling of the false lumen. Median follow-up was 7 months. Two patients developed distal aortic aneurysmal degeneration and underwent distal extension of the endograft with endoanchors. Mean time to degeneration was 41.5 weeks. Average decrease in aneurysm size since operation was 5 mm. No patient required an open operation. Endovascular electrocautery fenestration is a useful strategy for creating a distal landing zone in chronic descending aortic dissections. Longer term follow-up is needed to determine the longevity of the distal seal aided by septal fenestration.Fig 2Distal fenestration after thoracic endovascular aneurysm repair. Note the distal seal zone and persistent septum distal to the stent graft.View Large Image Figure ViewerDownload Hi-res image Download (PPT)