Fenestrated Aortic Arch Endovascular Repair for Aortic Diseases Extending to Ishimaru Zones 2 and 3

Introduction: Fenestrated endovascular aortic arch repair (fTEVAR) has been successfully used for the exclusion of aortic lesions extending to distal arch. This study aimed to present the outcomes of fTEVAR for the preservation of the left common carotid artery (LCCA) or left subclavian artery (LSA) in lesions extending to Ishimaru zone 2 and 3. Materials and Methods: A single-center retrospective analysis of patients managed with fTEVAR for the preservation of the LCCA or LSA, between September 1st, 2011 and December 31st, 2023, was conducted, following the STROBE guidelines. Only preloaded fenestrated custom-made devices (Cook Medical, Bloomington, IN, USA) were used. Primary outcomes were technical success, mortality, and stroke at 30 days. Survival and freedom from secondary intervention were assessed using Kaplan–Meier estimates. Results: Seventy-five patients were included [72 years (IQR 13), range 48–86; 66.7% males]; 54 scheduled for LSA and 21 for LCCA preservation. Seven (9.3%) were treated urgently. Twenty-one (28.0%) presented with aortic dissection; 19 type B. Ishimaru zone 2 disease extension was recorded in 44 (58.7%) and zone 3 in 32 (42.7%). Debranching was performed in 22 patients: 81.8% LCCA-LSA bypass. Technical success was 93.3% with proximal landing to zone 0 in 18.7% cases, zone 1 in 70.7%, and zone 2 in 10.6%. Six (8.0%) deaths were recorded at 30-days and 4 (5.3%) strokes; 2 (2.7%) major. All strokes were diagnosed in patients with LCCA preservation. The multivariate analysis showed LCCA bridging (OR 0.2, 95% CI 0.08–0.3, p < 0.001) as independently related to stroke. The median follow-up was 12 months. The survival and freedom from secondary intervention were 85.2% [standard error (SE) 4.7%] and 75.0% (SE 6.5%) at 12 months, respectively. Conclusion: Patients treated by fTEVAR for diseases extending to zones 2 and 3 presented encouraging early outcomes. LCCA bridging seems to be independently related to higher stroke rate. Preservation of the LSA seems safe, without neurological consequences. Clinical Impact: Fenestrated endovascular arch repair has been applied with acceptable mortality in distal aortic arch lesions. However, the published experience is limited. This retrospective study of 75 patients with disease extend to zones 2 and 3 showed encouraging early outcomes with 93.3% technical success, 8.0% mortality, and 5.3% strokes. The inclusion of the left common carotid artery to the repair was related to higher stroke rate, while the preservation of the left subclavian seems to have no neurological consequences.