Guangdong Provincial People's Hospital Performs ECMO-Supported TEVAR with Triple-Branch In Situ Fenestration

Clinical Baseline & Anatomical Challenges Recently, the Multidisciplinary Team (MDT) at Guangdong Provincial People's Hospital (GDPH), led by the Department of Vascular Surgery in collaboration with Anesthesiology and Cardiovascular Perfusion, managed an ultra-complex aortic arch pathology in a high-risk patient.

Technical Background: The patient presented with a recurrent giant dissecting aneurysm (maximum diameter: 77.3 mm) involving the aortic arch and descending aorta, 10 years after an open surgical graft replacement for a Type A aortic dissection (TAAD). The pathology was located at the distal anastomosis of the previous graft. Furthermore, the patient’s cardiac reserve was severely compromised due to a post-myocardial infarction ventricular aneurysm.

MDT Decision-Making & Surgical Planning A secondary open thoracotomy posed an unacceptably high mortality risk due to the patient's severe cardiac comorbidities. Conversely, a purely endovascular approach (TEVAR) required the complete reconstruction of the three supra-aortic branches to secure the proximal landing zone and maintain cerebral perfusion. Relying on high-resolution CTA and 3D reconstruction, the GDPH team precisely measured the aortic morphology and branch spatial relationships. An individualized strategy was formulated: Extracorporeal Membrane Oxygenation (ECMO) support combined with TEVAR and triple-branch in situ fenestration (ISF).

Standardized Surgical Pathway & Technical Breakdown The procedure integrated lesion exclusion, revascularization, and cerebral/myocardial protection into a synchronized workflow. The core technical steps were as follows:

1. ECMO Support & Hemodynamic Management: Given the patient's fragile cardiac function, veno-arterial ECMO (VA-ECMO) was established prior to the critical steps. This ensured stable systemic circulation and continuous cerebral perfusion during the complex arch manipulations.
2. Endovascular Exclusion: Guided by real-time imaging, the stent graft was precisely deployed to completely cover and exclude the dissecting aneurysm across the aortic arch and descending aorta.
3. Triple-Branch In Situ Fenestration (ISF): Utilizing advanced in situ fenestration techniques, the surgical team sequentially punctured the stent graft to reconstruct the brachiocephalic trunk (BCT), left common carotid artery (LCCA), and left subclavian artery (LSA).
4. Flow Restoration & Weaning: Following the precise alignment and bridging of the fenestrations, adequate blood flow to the brain and upper extremities was confirmed, allowing for safe weaning from ECMO support.

Clinical Outcomes & Advancement Immediate postoperative angiography confirmed the complete exclusion of the dissecting aneurysm with optimal stent placement. All three supra-aortic branches were fully patent, restoring normal cerebral and upper limb perfusion. The execution of this procedure highlights a systematic paradigm for complex aortic arch pathologies. By shifting from single-discipline surgery to an MDT-driven approach, Guangdong Provincial People's Hospital demonstrates a high-level clinical model focused on risk stratification, intraoperative organ protection, and precise endovascular reconstruction.