A Branch-Specific Combined Fenestration Strategy for Chronic Aortic Dissection With Severe Paravisceral True Lumen Compression

To evaluate a branch-specific combined fenestration strategy to address the technical challenges of severe true lumen (TL) compression during physician-modified fenestration (PMF)-based four-vessel visceral reconstruction in chronic aortic dissection (CAD).

This retrospective study enrolled twenty-three consecutive patients with aneurysmal CAD and severe paravisceral TL compression (minimum functional TL diameter ≤10 mm) treated between January 2020 and December 2024. All patients underwent visceral reconstruction using anterior-branch PMF and bilateral renal in situ laser fenestration (ISLF) performed following TL expansion. Endpoints included technical success (complete four-vessel reconstruction), 30-day mortality, target-vessel patency, and TL expansion.

Complete four-vessel visceral reconstruction was achieved in all 23 patients (92/92 target vessels). Renal ISLF was successful in all 46 renal arteries, with first-attempt success in 44 (96%). Distal aortic exclusion was required in 20 patients; one interval infrarenal rupture in the staged group was managed with emergency repair. Over a median follow-up of 17.0 months, primary target-vessel patency was 99% (91/92). The median minimum functional TL diameter increased from 8.0 mm preoperatively to 15.9 mm at one-year follow-up. No type I or III endoleak was identified. Thirty-day mortality was 0%. Transient spinal cord ischaemia occurred in one patient (4%), and acute kidney injury (KDIGO Stage 1) in two patients (9%), all resolving before discharge.

In highly selected CAD patients with severe TL compression, this combined fenestration strategy enabled complete four-vessel visceral reconstruction with satisfactory early target-vessel patency and no target-vessel loss, though longer follow-up in larger cohorts is required.