Abstract: Objective To analyze the early results of the application of surgically assisted short-distance retrograde needle puncture(SDRNP)technique for in situ fenestration in thoracic endovascular aortic repair(TEVAR)in patients with aortic arch disease. Methods A retrospective analysis was performed on 57 patients with aortic arch diseases between March 2021 and March 2023 who underwent TEVAR, and surgically assisted SDRNP in situ fenestration and reconstruction of the superior arch branches. There were 32 cases of aortic dissection, 15 cases of aortic aneurysm and 10 cases of penetrating ulcer. Inclusion criteria were aortic dissection/aneurysm, penetrating ulcer and other arch diseases, insufficient proximal landing zone for TEVAR, and stent graft covering the superior arch branches, and at least one fenestration. Exclusion criteria were the arch disease involving the ascending aorta, less than 20 mm from the opening of the coronary artery, or the diameter of the proximal landing zone greater than 45 mm, or the dominant left vertebral artery originating from the aortic arch. Results The success rate of the surgically assisted SDRNP technique was 98.2%(56/57). In 57 patients, simple left subclavian artery(LSA)fenestration was in 27 patients, LSA+left common carotid artery(LCCA)fenestration was in 18 patients, LCCA + brachiocephalic trunk(BCT)fenestration was in 1 patient, and LSA+LCCA+BCT fenestration was in 11 patients. SDRNP was performed 98 times, LSA 56 times, LCCA 30 times, and BCT 12 times. One patient with type A dissection was scheduled for triple fenestration. However, due to severe LSA distortion, SDRNP in the LSA failed after LCCA+BCT fenestration, and left carotid to left artery-left axillary artery bypass was performed. The mean operative time was(159.1±69.6)min. The mean operative time was(112.4±42.7)min for LSA fenestrations,(165.9±45.7)min for LSA+LCCA fenestrations, and(226.5±79.9)min for LSA+LCCA+BCT fenestrations. Postoperative complications included 1 paraplegia, 2 cerebral infarctions, 1 acute myocardial infarction and 1 limb numbness. Among them, one patient eventually died because of a massive cerebral infarction. Totally 51 patients were followed up with a median follow-up time of 19 months(ranging from 13 to 34 months). Post-operative CTA showed that 5 patients experienced endoleak, including 1 type Ⅰ, 1 type Ⅱ, and 3 type Ⅲ. Two cases with type Ⅲ endoleak were improved by coil embolization after re-intervention. There were no out-of-hospital cerebrovascular events or deaths. Conclusion Surgically assisted SDRNP in situ fenestration of the aortic arch is technically feasible, with the advantages of rapid and efficient manipulation and high success rate of fenestration, yielding acceptable short-term results in selected patient cohorts. However, the long-term effect still needs to be further monitored before the application of this technology can be popularized.

Key words: Aortic arch disease, Thoracic endovascular aortic repair, In situ needle fenestration, Short-distance, Surgical assistance