How I do it: Zone 0 arch treatment with laser in situ fenestrated endograft repair

Endovascular treatment of the aortic arch is an attractive option for the many patients who are at high risk for open surgical treatment. The complexity of the repair increases with more proximal treatment with a correlation between complications, such as strike, the closer to the aortic root. Given the paucity of commercially available branched devices, and the need for cervical debranching procedures, a total endovascular solution for the aortic arch is still lacking in the United States. Trial devised are being evaluated in highly selected anatomical cohorts; however, a critical need for a minimally invasive solution exists. Laser fenestration has been proposed as a mechanism to bridge the gap between trial and commercially available devices in poor risk surgical patients. In this article, we present techniques for laser in situ fenestrated endograft repair to the aortic arch.