Total Aortic Arch Repair With Double-Fenestrated Physician-Modified Endograft Under Local Anesthesia And Sedation: A Prospective Study

Objective: Endovascular aortic arch repair is an emerging procedure for all aortic pathologies, not only in high-risk patients. Little is known about the association between the type of anesthesia and outcomes. The aim of this study is to demonstrate the feasibility on short-term clinical outcomes of patients undergoing total aortic arch repair with double-fenestrated physician-modified endografts (PMEGs) under local anesthesia with sedation (also known as monitored anesthesia care [MAC]). Methods: From January to May 2024, data were prospectively collected on all procedures for total aortic arch repair with double-fenestrated PMEGs. Exclusion criteria were general anesthesia (GA). Study endpoints were technical success, time spent in the operating room, hospital stay, 30-day mortality, short-term complications, and re-interventions, according to the type of anesthesia. Results: Between January and May 2024, prospective data were collected on 20 procedures at a single referral center. A total of 14 procedures were performed under MAC. Technical success was 100%. In total, 71% of the patients were treated electively, and all major aortic pathologies were encountered (aneurysm, acute and chronic dissection, trauma, etc). In total, 93% of the procedures were done totally percutaneously, and MAC was no limitation for femoral surgical cutdown. No conversions from MAC to GA were necessary. The mean procedure time was 54 minutes (range=29-108 minutes). At 30 days follow-up, there were no major endoleaks, stent occlusions, or graft migrations. No patient died or experienced stroke. One patient had an asymptomatic retrograde dissection discovered on the follow-up computed tomography (CT) scan at 1 month requiring open surgical replacement. There were no cases of acute lung, myocardial, bowel, or kidney injury. The mean hospital stay was 4.9 days (range=2-23 days) and the mean intensive care unit (ICU) stay was 1.1 days (range=0-23 days). Conclusion: Endovascular total aortic arch repair with double-fenestrated PMEGs is feasible under local anesthesia with sedation. The short-term outcomes in a small patient cohort are promising for the development of MAC in aortic arch repair. Clinical Impact The outcomes of local anesthesia and sedation (also referred to as monitored anesthesia care) in endovascular aortic arch repair are not well-studied or widely reported. This study aims to demonstrate the feasibility and safety of this approach using physician-modified endografts for total aortic arch repair and showing it is a promising alternative to general anesthesia. Only a few exclusion criteria necessitate performing the procedure under general anesthesia and no conversions to general anesthesia were required.