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. 2021 Apr 15;28(4):524–529. doi: 10.1177/15266028211007475

Figure 3.

Figure 3.

In situ imaging during procedure. Through-and-through access from the left subclavian artery (LSA) to the left femoral artery (LFA) is established (A). A 0.018 roadrunner wire (Cook Medical, Bloomington, IN, USA) is folded in two to form a loop at the tip of a snare catheter sheath, transferred inside the aorta and widened (B). An extra-stiff Lunderquist wire (Cook Medical, Bloomington, IN, USA) is introduced through the LFA access to deliver the thoracic stent graft [34 mm diameter/113 mm length (Zenith Alpha Thoracic Endovascular Graft, Cook Medical, Bloomington, IN, USA)] through the snare wire loop and position it distal to the LSA takeoff (C). Next, a Turbo Elite laser catheter [2 mm diameter (Spectranetics, Colorado Springs, CO, USA)] is guided onto the stent-graft over a second 0.018 roadrunner wire. Laser-assisted in situ fenestration is performed while pulling both ends of the squid snare loop wire to maximize contact between stent graft fabric and laser catheter (D). The 0.018 roadrunner wire was advanced through the laser catheter into the ascending aorta and angioplasty balloons are used to expand the fenestration. Next, a covered stent graft [10 mm diameter/37 mm length (BeGraft, Bentley, Hechingen, Germany)] is deployed into the fenestration (E). A completion angiogram confirms exclusion of the penetrating aortic ulcer (PAU) without endoleak and sufficient flow through the stented in situ fenestration to the LSA (F).