In-situ fenestration with the Ankura Needle: single-center experience and narrative review

The aim of the study is to review the literature available about in-situ fenestration (ISF) techniques and their applicability to "zone 2" TEVAR for the revascularization of left subclavian artery (LSA), and retrospectively analyze a cohort of patients submitted to this type of endovascular approach in a single center. It is a single-center, retrospective, physician-initiated cohort study of patients treated in our institution from November 2023 to May 2024. Inclusion criteria were isolated left subclavian artery revascularization for elective or urgent/emergent 'zone 2' TEVAR. The primary outcome was the technical feasibility and the technical success of the procedure. Secondary outcomes were perioperative complications and follow-up. During the study period, 7 patients (all men; mean age of 73 + 9 [62-83] years) received ISNF for LSA revascularization, urgently in 4 patients (57%). In all cases (100%), it was possible to obtain the technical success with correct ISNF and exclusion of the aortic pathology. In the first two cases (28%), the procedure highlighted focal dissection of the axillary artery, necessitating PTA and stenting to properly restore the flow. No perioperative major adverse event occurred within 30 days. No patient underwent reoperation for aortic pathology; all patients are still alive today. Overall, postoperative CTA showed regular follow-up of the aortic pathology. Our initial case series analysis, in agreement with the current literature, suggests that ISNF for LSA revascularization in TEVAR provides encouraging midterm results and seems to be feasible and effective. ISF using the Ankura^™ device showed promising outcomes.