New Approach to Type B Aortic Dissection – Zone 2.5 Thoracic Endovascular Aortic Repair: A Case Report

New Approach to Type B Aortic Dissection – Zone 2.5 Thoracic Endovascular Aortic Repair: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report New Approach to Type B Aortic Dissection – Zone 2.5 Thoracic Endovascular Aortic Repair: A Case Report Hitoki Hashiguchi, Naomi Yasuda, Akihito Ohkawa This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7013528/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Jan, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 11 You are reading this latest preprint version Abstract We report a novel thoracic endovascular aortic repair (TEVAR) technique for complicated type B aortic dissection requiring zone 2 landing. A 42-year-old man presented with pulseless left femoral artery. Emergency TEVAR was performed using the left subclavian artery wall as a sealing zone to reduce the risk of endoleak. Postoperative recovery was uneventful, and the patient was discharged on day 8. CT demonstrated complete coverage of the entry tear, false lumen thrombosis, and preserved left subclavian perfusion. Follow-up CT showed favorable remodeling. This technique may be effective in patients with limited proximal sealing zones. Type B aortic dissection remodeling TEVAR Figures Figure 1 Figure 2 Figure 3 Introduction Thoracic endovascular aortic repair (TEVAR) is the optimal therapy of care for complicated type B aortic dissection (TBAD) 1 – 3 Approximately 20% of TEVAR for TBAD requires covering the left subclavian artery (LSA) for the proximal sealing zone 2 . Some cases of TEVAR require a zone 2 landing to cover the primary entry of the dissection. These cases require the protection of the LSA’s circulation. Many strategies have been used for LSA protection, including branched TEVAR, chimney technique, and bypass for LSA. Although short-term morbidity and mortality are low, TEVAR has subsequent complications, such as the risk of endoleaks and migration of the devices especially in those with revascularization LSA. We report the successful treatment of TBAD with a new approach in TEVAR. The patient provided written informed consent for the report of his case details and imaging studies. Case Report A 42-year-old man with a history of acute myocardial infarction several years ago was being followed at a nearby hospital. The patient was a current smoker, and his medical history included hypertension, dyslipidemia, and hyperuricemia. He presented with acute chest pain at a nearby hospital. Initially, he was diagnosed with cardiac angina, and nitric acid medications were administered. Computed tomography (CT) revealed TBAD. He was transferred to our hospital at 3 AM the next day owing to continuous chest pain. On arrival at our hospital, the chest pain had disappeared; however, the left limb pain worsened and the left limb got pale. CT angiography confirmed a zone 3 to bilateral external iliac TBAD with severe compression of the true lumen of the left common artery (Fig. 1 ). At 8 AM, his left femoral artery became pulseless. We attempted emergency TEVAR for complicated TBAD. The distance from the left subclavian artery to the primary entry tear was 8 mm. We first attempted a fenestrated endovascular aneurysm repair, however, the risk of endoleak owing to size mismatch and fenestration was high. We planned to use the wall of the LSA as a sealing zone which would decrease the risk of endoleak. The patient underwent general endotracheal anesthesia. The left brachial artery was obtained and a 5Fr Glideseath Slender (Terumo Corporation) was inserted and used for the angiography line. Ultrasound-guided access to the left femoral artery was obtained and a 9Fr sheath was used. Intravascular ultrasound (IVUS) was performed from the left femoral artery to the ascending aorta to confirm the true luminal placement of the wire. Perclose Proself sutures (Abbott Vascular) were placed in the left femoral artery at the 10:00 and 2:00 o’clock positions, and a 9Fr sheath (Medikit Co. Ltd) was inserted. Radifocus Guide Wire (Terumo Corporation) was used to cannulate the ascending aorta from the left femoral artery. IVUS was performed from the left femoral artery to the ascending aorta to confirm true luminal placement. Through the IVUS catheter, the Radifocus Guide Wire was exchanged for double-curve Lunderquist extra stiff wire (Cook Medical Inc.) Radifocus Guide Wire was used to cannulate the ascending aorta and pigtail catheter was advanced into the ascending aorta from left radial artery. Aortic arch angiography was performed and confirmed the origins of the Brachiocephalic artery (BCA), left carotid artery, and LSA. TEVAR was performed using Valiant Thoracic Stent Graft with the Captiva Delivery System (a tapered 30 mm to 26 mm diameter Closed Web device with a length of 150 mm: Medtronic Vascular). Blood pressure was maintained < 90 mmHg. The stent graft was advanced into the ascending aorta, the first stent was deployed at the level of the origin of BCA and then confirmed landing position at the lesser curvature of the aorta. The second stent was deployed and landed at the lesser curvature of the aorta, pulling the main shaft of the stent graft, and putting the first stent to the LSA. After fixing the first stent, the stent graft was deployed by pushing up the shaft of the device (Fig. 2 ). A pigtail catheter was maintained at the ascending aorta and it was useful to prevent the stent graft from being pushed distally of the aorta during deployment. Angiography revealed that the false lumen was not enhanced. The stent graft was exchanged for an 18Fr Sentrant sheath (Medtronic Vascular). The pigtail catheter advanced to the descending aorta from the left femoral artery. Angiography demonstrated that blood flow of the left iliac and femoral arteries improved. The operation time was 50 min. The patient’s hospital course was uncomplicated and he was discharged 8 days after the procedure. CT before discharge demonstrated coverage of the primary entry tear, thrombosis of the false lumen, and protection of LSA (Fig. 3 A). The patient underwent 3-month, 6-month, and 1-year (Fig. 3 B) follow-up CT, which showed remodeling of the false lumen. Discussion We report the case of a patient who presented with acute TBAD and underwent an operation with a new approach. TEVAR for TBAD is recognized as the standard therapy for patients with complications. TEVAR has been shown to decrease mortality compared to open surgery, expanding the true lumen and aortic remodeling 4 , 5 , but false lumen patency remains a problem and often requires reintervention to prevent late aortic rupture and death 6 . Coverage of the LSA is often required to achieve a dissection-free proximal seal zone and elimination of antegrade false lumen flow. Open debranching of the LSA, along with fenestrated grafts or physician-modified endografts, allows for more proximal coverage 6 – 8 . However, in the case of rupture, debranching performed before TEVAR or difficulty in cannulating the LSA with physician-modified endograft can delay the definitive seal of entry 2 . The chimney technique is also being used for revascularization of the LAS. However, it would require high-rate reintervention for type I endoleak from gutters or proximal stent compression 9 . This new procedure is advantageous because an extra procedure like de-branching or fenestration, is not required and the operation time is shorter. This procedure can be performed without extra prosthesis. Using the LSA as a sealing zone can make a seal zone longer. It might reduce the risk of type I endoleak and incomplete coverage of the entry. Attaching the first stent of the endograft to the wall of the LSA could prevent distal migration of the endograft. Conclusion We report the case of a patient who underwent TEVAR for TBAD using a novel technique, resulting in successful false lumen remodeling. This technique might be useful for patients with TBAD with short proximal sealing zones. Abbreviations TEVAR Thoracic endovascular aortic repair TBAD type B aortic dissection LSA the left subclavian artery CT Computed tomography Declarations Ethics approval and consent to participate: Not applicable. Availability of data and materials: Not applicable Conflict of Interest: Hitoki Hashiguchi received travel expenses from Medtronic; The other authors have no conflict of interest. Funding Sources: This research did not receive any specific grant. Authors' Contribution Study conception: HH Data collection: HH Analysis: HH, NY Manuscript preparation: HH, NY Critical review and revision: all authors Final approval of the article: all authors Accountability for all aspects of the work: all authors Acknowledgements We thank the cardiovascular operating-room nursing staff and radiology technologists at Hokkaido Prefectural Kitami Hospital for their invaluable assistance. References Rodriguez EJ, Martinez C, Anaya DM, et al. Acute type B aortic dissection one month after fenestrated EVAR procedure. EJVES Short Rep. 2019;44:38–43. Pitcher GS, Newhall KA, Stoner MC, et al. Gore TAG thoracic branch endograft for treatment of a subacute type B aortic dissection complicated by rupture. J Vasc Surg Cases Innov Tech. 2023;9:101193. Lou X, Duwayri YM, Jordan WD Jr., et al. The safety and efficacy of extended TEVAR in acute type B aortic dissection. Ann Thorac Surg. 2020;110:799–806. Leshnower BG, Duwayri YM, Chen EP, et al. Aortic remodeling after endovascular repair of complicated acute type B aortic dissection. Ann Thorac Surg. 2017;103:1878–85. Zeeshan A, Woo EY, Bavaria JE, et al. Thoracic endovascular aortic repair for acute complicated type B aortic dissection: superiority relative to conventional open surgical and medical therapy. J Thorac Cardiovasc Surg. 2010;140:S109–115. Rakestraw S, Feghali A, Nguyen K, et al. False lumen embolization as a rescue technique in the setting of acute and chronic dissecting aneurysms as adjunct to thoracic endovascular aortic repair. J Vasc Surg Cases Innov Tech. 2020;6:110–7. Joseph G, Thomson VS, Thankachen R, et al. A system for accurate deployment of unconstrained triple-fenestrated aortic arch endografts. J Endovasc Ther. 2022;29:893–903. Moqaddam M, Bacri C, Hireche K, et al. Short-term results of fenestrated physician-modified endografts for type 1a endoleak after conventional thoracic endovascular aortic repair. JTCVS Techniques. 2024;25:8–18. Zhang L, Wu MT, Zhu GL, et al. Off-the-shelf devices for treatment of thoracic aortic diseases: midterm follow-up of TEVAR with chimneys or physician-made fenestrations. J Endovasc Ther. 2020;27:132–42. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 03 Jan, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Revision requested 25 Oct, 2025 Reviews received at journal 25 Aug, 2025 Reviews received at journal 24 Aug, 2025 Reviews received at journal 19 Aug, 2025 Reviewers agreed at journal 16 Aug, 2025 Reviewers agreed at journal 16 Aug, 2025 Reviewers agreed at journal 13 Aug, 2025 Reviewers invited by journal 13 Aug, 2025 Editor assigned by journal 01 Jul, 2025 Submission checks completed at journal 01 Jul, 2025 First submitted to journal 30 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7013528","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":503235649,"identity":"2df3b464-da90-4913-ab3a-24d9a62d35d4","order_by":0,"name":"Hitoki Hashiguchi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIie3PoQoCQRCA4ZGBubJ49Q7FZ5hjQbHos4h1EasoKAhafACTvoLpsoug5cRqdDUb7Ab3zHKrzbB/Gpb5YBbA5/vDGAFKEx7VKFi8H0TZTTAne1kWGcDWEnISyAlgZxWpNwEnaQShNss+lWbxXd8eqlUlQHM9F5DmFDHZcBWp0uuyTrv2MJJSFR22Q4ovTEQVVY90ipYIO7uJ3YyznIy/JBvGiCKRk91XRCZL3jMJJfmYHgSh6y8nbcziORqv51lyGaTDdhhMza2IfAh/W/f5fD7fh16wGz7EptHQJQAAAABJRU5ErkJggg==","orcid":"","institution":"Hokkaido Prefectural Kitami Hospital","correspondingAuthor":true,"prefix":"","firstName":"Hitoki","middleName":"","lastName":"Hashiguchi","suffix":""},{"id":503235650,"identity":"00daabde-e96a-4a08-afaa-307e774b3674","order_by":1,"name":"Naomi Yasuda","email":"","orcid":"","institution":"Hokkaido Prefectural Kitami Hospital","correspondingAuthor":false,"prefix":"","firstName":"Naomi","middleName":"","lastName":"Yasuda","suffix":""},{"id":503235651,"identity":"3d3b56d6-964e-4968-9547-3856c0e30bf9","order_by":2,"name":"Akihito Ohkawa","email":"","orcid":"","institution":"Hokkaido Prefectural Kitami Hospital","correspondingAuthor":false,"prefix":"","firstName":"Akihito","middleName":"","lastName":"Ohkawa","suffix":""}],"badges":[],"createdAt":"2025-06-30 18:53:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7013528/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7013528/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13019-025-03828-6","type":"published","date":"2026-01-03T15:57:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":89634474,"identity":"d1a691c2-bfcf-4780-b21d-ac29e1c066fc","added_by":"auto","created_at":"2025-08-22 07:06:39","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":203490,"visible":true,"origin":"","legend":"\u003cp\u003eEnhanced computed tomography (CT) scan at onset. CT reveals that the dissection occurs from the distal to the left subclavian artery.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7013528/v1/4dc8c6be3a73836c27565bc1.jpeg"},{"id":89634475,"identity":"bbb1925e-729f-487c-90b8-d2fd19954027","added_by":"auto","created_at":"2025-08-22 07:06:39","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":242308,"visible":true,"origin":"","legend":"\u003cp\u003eAngiography in operation. The proximal edge of the stent graft is placed in the left subclavian artery (LSA) and the proximal seal zone is obtained. Angiography shows that LSA is patent.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7013528/v1/850533ef25d1372110206c22.jpeg"},{"id":89634476,"identity":"baef18a0-fc6d-4d51-aeea-3d6dfd198f47","added_by":"auto","created_at":"2025-08-22 07:06:39","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":529375,"visible":true,"origin":"","legend":"\u003cp\u003eComputed tomography scan at 4 days after thoracic endovascular aortic repair (TEVAR) (A) and 1 year after TEVAR (B).\u003c/p\u003e\n\u003cp\u003e(A) False lumen covered with stent graft is thrombosed.\u003c/p\u003e\n\u003cp\u003e(B) Remodeling of false lumen is achieved.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7013528/v1/7e721432d9057e124ca485df.jpeg"},{"id":99545292,"identity":"1629a1ee-5e5d-451a-8213-e62f7d2c0914","added_by":"auto","created_at":"2026-01-05 16:05:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1294466,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7013528/v1/f521cb1e-eecd-447b-a7a7-6b548d94c386.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"New Approach to Type B Aortic Dissection – Zone 2.5 Thoracic Endovascular Aortic Repair: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThoracic endovascular aortic repair (TEVAR) is the optimal therapy of care for complicated type B aortic dissection (TBAD) \u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Approximately 20% of TEVAR for TBAD requires covering the left subclavian artery (LSA) for the proximal sealing zone\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Some cases of TEVAR require a zone 2 landing to cover the primary entry of the dissection. These cases require the protection of the LSA\u0026rsquo;s circulation. Many strategies have been used for LSA protection, including branched TEVAR, chimney technique, and bypass for LSA. Although short-term morbidity and mortality are low, TEVAR has subsequent complications, such as the risk of endoleaks and migration of the devices especially in those with revascularization LSA. We report the successful treatment of TBAD with a new approach in TEVAR. The patient provided written informed consent for the report of his case details and imaging studies.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eA 42-year-old man with a history of acute myocardial infarction several years ago was being followed at a nearby hospital. The patient was a current smoker, and his medical history included hypertension, dyslipidemia, and hyperuricemia. He presented with acute chest pain at a nearby hospital. Initially, he was diagnosed with cardiac angina, and nitric acid medications were administered. Computed tomography (CT) revealed TBAD. He was transferred to our hospital at 3 AM the next day owing to continuous chest pain. On arrival at our hospital, the chest pain had disappeared; however, the left limb pain worsened and the left limb got pale. CT angiography confirmed a zone 3 to bilateral external iliac TBAD with severe compression of the true lumen of the left common artery (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). At 8 AM, his left femoral artery became pulseless. We attempted emergency TEVAR for complicated TBAD. The distance from the left subclavian artery to the primary entry tear was 8 mm. We first attempted a fenestrated endovascular aneurysm repair, however, the risk of endoleak owing to size mismatch and fenestration was high. We planned to use the wall of the LSA as a sealing zone which would decrease the risk of endoleak.\u003c/p\u003e\u003cp\u003eThe patient underwent general endotracheal anesthesia. The left brachial artery was obtained and a 5Fr Glideseath Slender (Terumo Corporation) was inserted and used for the angiography line. Ultrasound-guided access to the left femoral artery was obtained and a 9Fr sheath was used. Intravascular ultrasound (IVUS) was performed from the left femoral artery to the ascending aorta to confirm the true luminal placement of the wire. Perclose Proself sutures (Abbott Vascular) were placed in the left femoral artery at the 10:00 and 2:00 o\u0026rsquo;clock positions, and a 9Fr sheath (Medikit Co. Ltd) was inserted. Radifocus Guide Wire (Terumo Corporation) was used to cannulate the ascending aorta from the left femoral artery. IVUS was performed from the left femoral artery to the ascending aorta to confirm true luminal placement. Through the IVUS catheter, the Radifocus Guide Wire was exchanged for double-curve Lunderquist extra stiff wire (Cook Medical Inc.) Radifocus Guide Wire was used to cannulate the ascending aorta and pigtail catheter was advanced into the ascending aorta from left radial artery. Aortic arch angiography was performed and confirmed the origins of the Brachiocephalic artery (BCA), left carotid artery, and LSA. TEVAR was performed using Valiant Thoracic Stent Graft with the Captiva Delivery System (a tapered 30 mm to 26 mm diameter Closed Web device with a length of 150 mm: Medtronic Vascular). Blood pressure was maintained\u0026thinsp;\u0026lt;\u0026thinsp;90 mmHg. The stent graft was advanced into the ascending aorta, the first stent was deployed at the level of the origin of BCA and then confirmed landing position at the lesser curvature of the aorta. The second stent was deployed and landed at the lesser curvature of the aorta, pulling the main shaft of the stent graft, and putting the first stent to the LSA. After fixing the first stent, the stent graft was deployed by pushing up the shaft of the device (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A pigtail catheter was maintained at the ascending aorta and it was useful to prevent the stent graft from being pushed distally of the aorta during deployment. Angiography revealed that the false lumen was not enhanced. The stent graft was exchanged for an 18Fr Sentrant sheath (Medtronic Vascular). The pigtail catheter advanced to the descending aorta from the left femoral artery. Angiography demonstrated that blood flow of the left iliac and femoral arteries improved. The operation time was 50 min. The patient\u0026rsquo;s hospital course was uncomplicated and he was discharged 8 days after the procedure. CT before discharge demonstrated coverage of the primary entry tear, thrombosis of the false lumen, and protection of LSA (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). The patient underwent 3-month, 6-month, and 1-year (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB) follow-up CT, which showed remodeling of the false lumen.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe report the case of a patient who presented with acute TBAD and underwent an operation with a new approach. TEVAR for TBAD is recognized as the standard therapy for patients with complications. TEVAR has been shown to decrease mortality compared to open surgery, expanding the true lumen and aortic remodeling\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e, but false lumen patency remains a problem and often requires reintervention to prevent late aortic rupture and death\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Coverage of the LSA is often required to achieve a dissection-free proximal seal zone and elimination of antegrade false lumen flow. Open debranching of the LSA, along with fenestrated grafts or physician-modified endografts, allows for more proximal coverage\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. However, in the case of rupture, debranching performed before TEVAR or difficulty in cannulating the LSA with physician-modified endograft can delay the definitive seal of entry\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. The chimney technique is also being used for revascularization of the LAS. However, it would require high-rate reintervention for type I endoleak from gutters or proximal stent compression\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. This new procedure is advantageous because an extra procedure like de-branching or fenestration, is not required and the operation time is shorter. This procedure can be performed without extra prosthesis. Using the LSA as a sealing zone can make a seal zone longer. It might reduce the risk of type I endoleak and incomplete coverage of the entry. Attaching the first stent of the endograft to the wall of the LSA could prevent distal migration of the endograft.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe report the case of a patient who underwent TEVAR for TBAD using a novel technique, resulting in successful false lumen remodeling. This technique might be useful for patients with TBAD with short proximal sealing zones.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTEVAR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eThoracic endovascular aortic repair\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTBAD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003etype B aortic dissection\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLSA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ethe left subclavian artery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComputed tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHitoki Hashiguchi received travel expenses from Medtronic; The other authors have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Sources:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eStudy conception: HH\u003c/li\u003e\n \u003cli\u003eData collection: HH\u003c/li\u003e\n \u003cli\u003eAnalysis: HH, NY\u003c/li\u003e\n \u003cli\u003eManuscript preparation: HH, NY\u003c/li\u003e\n \u003cli\u003eCritical review and revision: all authors\u003c/li\u003e\n \u003cli\u003eFinal approval of the article: all authors\u003c/li\u003e\n \u003cli\u003eAccountability for all aspects of the work: all authors\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the cardiovascular operating-room nursing staff and radiology technologists at Hokkaido Prefectural Kitami Hospital for their invaluable assistance.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRodriguez EJ, Martinez C, Anaya DM, et al. Acute type B aortic dissection one month after fenestrated EVAR procedure. EJVES Short Rep. 2019;44:38\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePitcher GS, Newhall KA, Stoner MC, et al. Gore TAG thoracic branch endograft for treatment of a subacute type B aortic dissection complicated by rupture. J Vasc Surg Cases Innov Tech. 2023;9:101193.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLou X, Duwayri YM, Jordan WD Jr., et al. The safety and efficacy of extended TEVAR in acute type B aortic dissection. Ann Thorac Surg. 2020;110:799\u0026ndash;806.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLeshnower BG, Duwayri YM, Chen EP, et al. Aortic remodeling after endovascular repair of complicated acute type B aortic dissection. Ann Thorac Surg. 2017;103:1878\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZeeshan A, Woo EY, Bavaria JE, et al. Thoracic endovascular aortic repair for acute complicated type B aortic dissection: superiority relative to conventional open surgical and medical therapy. J Thorac Cardiovasc Surg. 2010;140:S109\u0026ndash;115.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRakestraw S, Feghali A, Nguyen K, et al. False lumen embolization as a rescue technique in the setting of acute and chronic dissecting aneurysms as adjunct to thoracic endovascular aortic repair. J Vasc Surg Cases Innov Tech. 2020;6:110\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJoseph G, Thomson VS, Thankachen R, et al. A system for accurate deployment of unconstrained triple-fenestrated aortic arch endografts. J Endovasc Ther. 2022;29:893\u0026ndash;903.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoqaddam M, Bacri C, Hireche K, et al. Short-term results of fenestrated physician-modified endografts for type 1a endoleak after conventional thoracic endovascular aortic repair. JTCVS Techniques. 2024;25:8\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang L, Wu MT, Zhu GL, et al. Off-the-shelf devices for treatment of thoracic aortic diseases: midterm follow-up of TEVAR with chimneys or physician-made fenestrations. J Endovasc Ther. 2020;27:132\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Type B aortic dissection, remodeling, TEVAR","lastPublishedDoi":"10.21203/rs.3.rs-7013528/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7013528/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWe report a novel thoracic endovascular aortic repair (TEVAR) technique for complicated type B aortic dissection requiring zone 2 landing. A 42-year-old man presented with pulseless left femoral artery. Emergency TEVAR was performed using the left subclavian artery wall as a sealing zone to reduce the risk of endoleak. Postoperative recovery was uneventful, and the patient was discharged on day 8. CT demonstrated complete coverage of the entry tear, false lumen thrombosis, and preserved left subclavian perfusion. Follow-up CT showed favorable remodeling. This technique may be effective in patients with limited proximal sealing zones.\u003c/p\u003e","manuscriptTitle":"New Approach to Type B Aortic Dissection – Zone 2.5 Thoracic Endovascular Aortic Repair: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-22 06:58:34","doi":"10.21203/rs.3.rs-7013528/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-25T07:54:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-25T18:21:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-24T07:23:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-19T15:39:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"210405762218749999943973677045837332009","date":"2025-08-16T08:22:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"152164060962282990513163585194272921313","date":"2025-08-16T06:47:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"217703945662130255266270458439535591978","date":"2025-08-13T11:37:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-13T10:29:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-01T05:07:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-01T05:05:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-06-30T18:39:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b8da0bee-22d9-4fcd-b406-983d070d06f7","owner":[],"postedDate":"August 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-05T16:00:46+00:00","versionOfRecord":{"articleIdentity":"rs-7013528","link":"https://doi.org/10.1186/s13019-025-03828-6","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2026-01-03 15:57:51","publishedOnDateReadable":"January 3rd, 2026"},"versionCreatedAt":"2025-08-22 06:58:34","video":"","vorDoi":"10.1186/s13019-025-03828-6","vorDoiUrl":"https://doi.org/10.1186/s13019-025-03828-6","workflowStages":[]},"version":"v1","identity":"rs-7013528","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7013528","identity":"rs-7013528","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}