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

ObjectivesMal-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.MethodsA 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.ResultsOn 1 year follow-up, the patient's dizziness has resolved, and he has maintained normotension via anti-hypertensives.ConclusionLaser 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.