Preloaded Physician-Modified Thoracic Endovascular Aortic Repair to Achieve Left Subclavian Artery Fenestration Alignment in Zone 2.
Emiel W M Huistra, Wajdi Alrawi, Ignace F J Tielliu et al.
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Case in brief
A patient with an intramural aortic hematoma extending to the level of the left subclavian artery (LSA) underwent zone 2 thoracic endovascular aortic repair. The team modified a thoracic endograft with an LSA fenestration, a preloaded guidewire, and diameter-reducing ties. The wire was passed from femoral to brachial access to help orient the graft. A balloon positioned across the fenestration and LSA was inflated while the ties were released, facilitating alignment; the LSA was then stented with a balloon-expandable covered stent. Completion angiography and follow-up CT angiography demonstrated technical success.
What made this case unusual
The technique combined a preloaded LSA fenestration and diameter-reducing ties, with balloon inflation during tie release, to address the challenge of aligning a physician-modified graft fenestration with the LSA in zone 2.
Diagnostic / clinical pearl
For zone 2 TEVAR requiring LSA preservation, a through-and-through wire and diameter-reducing ties may help orient and align a physician-modified graft fenestration; this report describes balloon inflation during tie release as part of that approach.