Hybrid Zone 1 TEVAR Using a Single-Fenestrated PMEG After Left Subclavian-to-Left Common Carotid Bypass: A Case Report

Hybrid Zone 1 TEVAR Using a Single-Fenestrated PMEG After Left Subclavian-to-Left Common Carotid Bypass: 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 Hybrid Zone 1 TEVAR Using a Single-Fenestrated PMEG After Left Subclavian-to-Left Common Carotid Bypass: A Case Report Seok Beom Hong, June Lee, Jung Seob Yoon, Do Hyung Lim, Won Kyu Lee, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8381576/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Apr, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 13 You are reading this latest preprint version Abstract Background Aortic arch disease poses significant challenges because of its complex anatomy and the necessity to maintain blood flow to the brain and upper extremities. Traditional surgical repair involves considerable perioperative risks, especially for elderly or high-risk patients. Meanwhile, thoracic endovascular aortic repair (TEVAR) in the aortic arch faces limitations due to the involvement of supra-aortic vessels and the absence of specialized devices. As a solution, physician-modified endografts (PMEGs) have emerged as a viable option to facilitate TEVAR in difficult arch segments. Case presentation A 75-year-old woman with a history of rectal cancer presented with chest discomfort. Imaging revealed a 4.5-cm lesion in the aortic arch that involved the origin of the left subclavian artery (LSA) and showed signs of impending rupture. Due to the limited proximal landing zone at Zone 2 (8 mm) and the suitable anatomy at Zone 1 (21 mm), a hybrid approach was planned. A single-fenestrated PMEG targeting the left common carotid artery (LCCA) was created on the back table, with a preloaded wire to ensure precise alignment of the fenestration. The procedure also included a bypass from the LSA to the LCCA. The PMEG was deployed through femoral access, and the fenestration was bridged with a covered stent graft. Postoperative imaging revealed a small transient endoleak that resolved spontaneously during a follow-up computed tomography (CT) scan one month later. The patient recovered well and was discharged on postoperative day 8. Conclusions The combination of single-fenestrated PMEG with LSA-to-LCCA bypass offers a safe and effective hybrid strategy for Zone 1 TEVAR in high-risk patients. This method ensures secure proximal sealing, maintains cerebral perfusion, and successfully excludes the diseased arch segment. PMEG-based hybrid repair serves as a viable alternative when dedicated arch devices are either unavailable or used off-label, especially in anatomically favorable cases. Aortic arch disease Zone 1 TEVAR Physician-modified endograft Hybrid arch repair Fenestrated stent graft Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Aortic arch disease presents significant challenges due to its intricate anatomy and the necessity to preserve blood flow to the brain and upper extremities. While open surgical replacement has traditionally been seen as the gold standard, arch surgery is highly demanding. It requires extensive surgical exposure, cardiopulmonary bypass, circulatory arrest, and sometimes multiple stages of procedures. Consequently, perioperative morbidity and mortality rates are considerable, especially in elderly or high-risk patients.[ 1 , 2 ] To mitigate these risks, hybrid arch repair techniques that combine supra-aortic debranching with endovascular stent-grafting have been developed. Concurrently, advancements in endovascular therapy have facilitated the gradual expansion of TEVAR into the arch. However, TEVAR in Zone 1 or Zone 0 is still constrained by the involvement of supra-aortic branches and the lack of widely accessible, dedicated arch devices, resulting in these procedures being considered off-label.[ 3 ] PMEGs have emerged as a practical and flexible solution in this context. While not yet widely adopted, PMEGs enable the modification of commercially available devices to fit patient-specific arch anatomy when off-the-shelf devices are either unsuitable or unavailable. Initially introduced in the early 2000s for complex abdominal and thoracoabdominal aortic aneurysms, PMEGs have since expanded their application to aortic arch pathology [ 4 ]. Their value is especially clear in high-risk or emergent situations, such as impending rupture, where the lengthy manufacturing time for custom-made devices makes them impractical. In this report, we present a case of single-fenestrated PMEG for Zone 1 TEVAR following a left subclavian artery to left common carotid artery bypass. This hybrid approach maintained cerebral perfusion while effectively excluding an unstable aortic arch lesion. Case presentation A 75-year-old woman with a history of rectal cancer, treated surgically ten years ago and currently in complete remission, was referred to our department after experiencing chest discomfort for one month. A chest CT performed at an outside hospital revealed signs of impending rupture of the aortic arch (Fig. 1 ). The CT findings indicated an irregular luminal outpouching of the aortic arch, accompanied by a surrounding heterogeneous high-attenuation lesion that had progressively enlarged from 3.5 cm to 4.5 cm in long-axis diameter over the past two months. No definite mediastinal or pleural fluid collections were observed. The lesion involved the origin of the LSA, and prompting initial assessments that suggested the need for total arch replacement using a frozen elephant trunk technique. However, both the ascending and descending thoracic aorta were nearly normal in diameter and morphology, making extensive open arch replacement less favorable. The landing zone length at Zone 2 was only 8 mm, which was insufficient for standard TEVAR, while Zone 1 offered a 21-mm proximal landing zone, allowing for the possibility of a hybrid endovascular approach. The diameter of the LCCA measured 6–7 mm. Due to our limited experience with PMEGs and the technical complexity of multi-fenestrated designs, we decided to implement a single-fenestration PMEG targeting only the LCCA, combined with an LSA-to-LCCA bypass and LSA occlusion as part of a hybrid arch repair strategy. On the back table, we created a single-fenestrated stent graft using a Valiant Captivia device. A 7-mm fenestration was made approximately 5 mm distal to the proximal edge of the graft using ophthalmic electrocautery, and it was reinforced internally with an EN Snare (Merit Medical, South Jordan, UT, USA) and 5 − 0 prolene sutures for circumferential marking (Fig. 2 ). For catheter guidance, we preloaded a 0.018-inch Gradius wire (Asahi Intecc, Aichi, Japan) through a puncture in the device’s outer sheath, passed it through the stent graft, and externalized it through the fenestration before resheathing. Under general anesthesia, an incision was made in the left neck, and a left subclavian artery to left common carotid artery (LSA-to-LCCA) bypass was performed using an 8-mm Intergard knitted graft (Abbott Medical, Plymouth, MN, USA). An 8-Fr sheath was then inserted through the graft. The right common femoral artery (CFA) was accessed under ultrasound guidance, and two Pro-Glide Vascular Closure Devices (Abbott Medical, Plymouth, MN, USA) were employed for pre-closure. A 5-French sheath was placed in the left CFA, and the LSA ostium was occluded using a 14-mm Amplatzer vascular plug (Abbott Medical, Plymouth, MN, USA). For distal landing, a 30 × 30 × 100 mm Valiant Captivia stent graft (Medtronic, Minneapolis, MN, USA) was deployed via the right CFA using a bottom-up approach. A 14-Fr sheath was introduced into the right CFA. Using a through-and-through wire technique between the LCCA bypass graft and the right CFA, the preloaded wire of the PMEG was exteriorized to facilitate selective catheterization of the LCCA. The single-fenestrated PMEG (Valiant Captivia, 34 × 34 × 100 mm) was deployed with the fenestration precisely aligned to the LCCA ostium. The fenestration was predilated with an 8 × 20-mm Mustang balloon (Boston Scientific, Marlborough, MA, USA) at 10 atm. An 8 × 27-mm BeGraft covered stent (Bentley InnoMed, Hechingen, Germany) was then delivered from the LCCA into the fenestration, with the proximal portion flared inside the aortic stent graft using high-pressure ballooning up to 20 atm. Completion aortography showed no endoleak (Fig. 3 ). Postoperative CT scans showed a small, non-persistent type IA or II endoleak that resolved spontaneously by the follow-up CT one month later, confirming complete exclusion of the lesion (Fig. 4 ). The total operative time was 4 hours and 30 minutes, and the patient was discharged on postoperative day 8 without complications. Discussion Aortic arch pathology is one of the most technically challenging areas for endovascular intervention, primarily due to the arch's complex geometry, high hemodynamic forces, and the critical necessity to preserve cerebral perfusion [ 5 , 6 ]. Although open total arch replacement has traditionally been the standard treatment, the procedure imposes a significant physiological burden—especially on elderly or high-risk patients—due to the necessity of cardiopulmonary bypass, circulatory arrest, and extensive surgical exposure. While TEVAR has become a standard therapy for descending thoracic aortic disease, its application in the arch remains limited, particularly in Zone 1 and Zone 0, where current commercially available devices do not have formal instructions for use.[ 7 , 8 ] With the advancement of endovascular technologies, there has been a growing interest in hybrid strategies and fully endovascular arch repairs. However, the use of proximal arch TEVAR (Zone 1 or Zone 0) is limited by the scarcity of widely available, dedicated branched or fenestrated arch endografts, many of which are still in the investigational stage or approved only for dissection in specific countries. As a result, when open repair presents significant risks and dedicated devices are unavailable, clinicians often resort to hybrid debranching or physician-modified endografts (PMEGs) to establish adequate landing zones while preserving perfusion to the supra-aortic branches. PMEGs were first developed in the early 2000s to address complex abdominal and thoracoabdominal aortic disease, and their application has since expanded to include the aortic arch. Their flexibility and immediate availability make them especially valuable in emergency situations, such as impending ruptures, where rapid clinical deterioration prevents the time needed for manufacturing custom-made devices.[ 9 , 10 ] PMEGs, while technically demanding—particularly with multi-fenestration designs—provide customized device geometry, enhanced sealing zones, and the benefit of avoiding extensive open surgery. In this case, open total arch replacement with a frozen elephant trunk was initially considered due to the lesion's involvement at the origin of the left subclavian artery, which exhibited radiologic signs of impending rupture. However, the ascending and descending thoracic aorta were nearly normal in diameter, and the patient, an elderly individual with a prior oncologic history, was at high risk. These factors made a minimally invasive approach more suitable. The landing zone in Zone 2 was inadequate, offering only an 8-mm seal zone, while Zone 1 presented a more favorable 21-mm proximal landing zone. This anatomical configuration strongly supported the choice of a Zone 1 hybrid TEVAR with carotid revascularization. Additionally, considering the operator’s limited prior experience with PMEGs, a single-fenestration design was deemed more technically reliable than a two-fenestration configuration. This further reinforced the decision to proceed with a Zone 1 hybrid TEVAR combined with an LSA-to-LCCA bypass, simplifying the procedure while ensuring technical success. PMEGs provide several advantages in specific cases: they enable personalized alignment with branch vessels, create better seal zones than scallops or chimney techniques, and reduce the morbidity associated with extensive open repairs.[ 11 , 12 ] However, concerns persist about their durability, the risk of endoleak, and the technical challenges associated with back-table modifications, especially in multi-fenestrated configurations.[ 13 , 14 ] In this case, a single fenestration was selected to reduce procedural complexity while ensuring sufficient cerebral perfusion through the LCCA. The preloaded wire strategy enabled accurate alignment of the fenestration.[ 15 ] A small early Type IA or II endoleak was observed on postoperative imaging but resolved spontaneously by the one-month follow-up CT. This finding aligns with previous PMEG reports, which have shown low rates of persistent endoleak when there is adequate apposition between the fenestration and the bridging stent.[ 16 , 17 ] In TEVAR procedures conducted in Zone 2 or more proximal segments, it is crucial to consider the risk of retrograde type A dissection. This complication has been reported in about 2.5% of cases and carries a mortality rate of up to 37%, especially when using devices with a free-flow segment. Therefore, careful planning and device selection are essential to minimize this risk. [ 18 ] The patient had a smooth recovery and was discharged on postoperative day 8, illustrating the feasibility and safety of this approach for carefully selected patients. This case underscores the significance of personalized treatment planning in arch pathology, particularly when the anatomy is suitable for an endovascular-first strategy but dedicated devices are scarce. A hybrid repair combined with a single-fenestrated PMEG offers a valuable alternative for Zone 1 lesions in high-risk patients. Conclusions The use of single-fenestrated PMEG for Zone 1 TEVAR, along with a bypass from the LSA to the LCCA, offers an effective and less invasive treatment for complex aortic arch lesions in elderly, high-risk patients. This approach ensures secure proximal sealing, maintains cerebral perfusion, and successfully excludes the diseased segment of the arch without significant complications. In situations where dedicated arch devices are unavailable or used off-label, a PMEG-based hybrid repair can be a practical and safe option, provided that the anatomical conditions are suitable and careful planning is executed. Abbreviations TEVAR : Thoracic endovascular aortic repair PMEGs : Physician-modified endografts LSA : Left subclavian artery LCCA : Left common carotid artery CT : Computed tomography Declarations Acknowledgments This manuscript was proofread and edited by the professional English editors at HARRISCO. Authors’ contributions DYK and SBH contributed to the study design, research, and manuscript writing. JL, DHL, WKL, and JSY were involved in manuscript editing and conducting the research. DYK performed the surgery and procedure, with DHL and WKL assisting during the procedure. All authors have read and approved the final version of the manuscript. Funding This work received no funding. Availability of data and materials No datasets were generated or analyzed during the current study. Ethics approval and consent to participate Consent for participation in this study was obtained from the patient. Consent for publication Consent was obtained from the patient for publishing this report and any accompanying images. Competing interests The authors have no competing interests relevant to this report to disclose. References Lodo V, Centofanti P. Current techniques of repair of aortic arch pathologies and the role of the aortic team. Indian J Thorac Cardiovasc Surg. 2024;40(4):451–60. Xydas S, et al. Hybrid repair of aortic arch aneurysms: a comprehensive review. J Thorac Dis. 2017;9(Suppl 7):S629–34. Gao X, et al. Efficacy and safety of debranching technique with zone 1 thoracic endovascular aortic repair in high-risk patients with distal aortic arch lesions. J Cardiothorac Surg. 2025;20(1):239. Zhu J, et al. Fenestrated Thoracic Endovascular Aortic Repair Using Physician-Modified Stent Grafts (PMSGs) in Zone 0 and Zone 1 for Aortic Arch Diseases. Cardiovasc Intervent Radiol. 2019;42(1):19–27. Kanaoka Y, et al. Technical challenges in endovascular repair of complex thoracic aortic aneurysms. Ann Vasc Dis. 2012;5(1):21–9. Rylski B. Endovascular approach to complex aortic arch pathologies: state of the art. Kardiochir Torakochirurgia Pol. 2016;13(1):1–2. Halbert S, et al. Endovascular Repair of Zone 0 Ascending Aortic Aneurysm: A Review of Current Knowledge and Developing Technology. Aorta (Stamford). 2024;12(1):13–9. McClure RS, et al. Zone 0 Aortic Arch Reconstruction Using the RelayBranch Thoracic Stent Graft. CJC Open. 2021;3(10):1307–9. Jędrzejczak T, et al. Physician-modified endograft in ruptured aortic arch. Postepy Kardiol Interwencyjnej. 2022;18(1):70–3. Solano A, et al. Physician Modified Endograft for Ruptured Dissecting Aortic Arch Aneurysm. Vasc Endovascular Surg. 2024;58(8):876–83. Lee KB, et al. Early Results and Feasibility of Total Endovascular Aortic Arch Repair Using 3-Vessel Company-Manufactured and Physician-Modified Stent-Grafts. J Endovasc Ther. 2024;31(6):1197–207. Kansagra K, et al. Advanced endografting techniques: snorkels, chimneys, periscopes, fenestrations, and branched endografts. Cardiovasc Diagn Ther. 2018;8(Suppl 1):S175–83. Moqaddam M, et al. Short-term results of fenestrated physician-modified endografts for type1a endoleak after conventional thoracic endovascular aortic repair. JTCVS Tech. 2024;25:8–18. Canaud L, et al. Total Arch Thoracic Endovascular Aortic Repair Using Double Fenestrated Physician-Modified Stent-Grafts: 100 Patients. J Endovasc Ther. 2024;31(1):89–97. Huistra EWM et al. Preloaded Physician-Modified Thoracic Endovascular Aortic Repair to Achieve Left Subclavian Artery Fenestration Alignment in Zone 2. J Endovasc Ther, 2025: p. 15266028251344882. Chassin-Trubert L, et al. Double fenestrated physician-modified stent-grafts for total aortic arch repair in 50 patients. J Vasc Surg. 2021;73(6):1898. –1905.e1. Wen Q, et al. Physician Modified Fenestrated Endografts for Endovascular Aortic Arch Repair in Zone 0. Eur J Vasc Endovasc Surg. 2024;68(2):190–9. Chen Y et al. Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis. J Am Heart Assoc, 2017. 6(9). Additional Declarations No competing interests reported. Supplementary Files SupplementaryPMEGarchcase.mp4 Supplement Video 1 : Hybrid Zone 1 Fenestrated TEVAR with PMEG Procedure Cite Share Download PDF Status: Published Journal Publication published 20 Apr, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Revision requested 05 Apr, 2026 Reviews received at journal 13 Feb, 2026 Reviews received at journal 10 Feb, 2026 Reviews received at journal 10 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviews received at journal 03 Feb, 2026 Reviewers agreed at journal 03 Feb, 2026 Reviewers agreed at journal 03 Feb, 2026 Reviewers invited by journal 03 Feb, 2026 Editor assigned by journal 19 Dec, 2025 Submission checks completed at journal 19 Dec, 2025 First submitted to journal 16 Dec, 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. 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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-8381576","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":585137194,"identity":"4d259f08-8800-4c56-90cf-7fdfc0cabeea","order_by":0,"name":"Seok Beom Hong","email":"","orcid":"","institution":"Seoul St.Mary's hospital, College of Medicine, The Catholic University of Korea","correspondingAuthor":false,"prefix":"","firstName":"Seok","middleName":"Beom","lastName":"Hong","suffix":""},{"id":585137195,"identity":"b21316c1-89cc-40ef-9c40-447d3a52c726","order_by":1,"name":"June Lee","email":"","orcid":"","institution":"Uijeongbu Eulji Medical Center, Eulji University","correspondingAuthor":false,"prefix":"","firstName":"June","middleName":"","lastName":"Lee","suffix":""},{"id":585137196,"identity":"a8eb507c-f231-4e38-a7f0-dff0214cd950","order_by":2,"name":"Jung Seob Yoon","email":"","orcid":"","institution":"Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea","correspondingAuthor":false,"prefix":"","firstName":"Jung","middleName":"Seob","lastName":"Yoon","suffix":""},{"id":585137198,"identity":"75e12b37-8978-45b4-98e9-08b155292ec3","order_by":3,"name":"Do Hyung Lim","email":"","orcid":"","institution":"Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea","correspondingAuthor":false,"prefix":"","firstName":"Do","middleName":"Hyung","lastName":"Lim","suffix":""},{"id":585137201,"identity":"a045f590-ea07-4ebd-aed9-462ee0435ca5","order_by":4,"name":"Won Kyu Lee","email":"","orcid":"","institution":"Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea","correspondingAuthor":false,"prefix":"","firstName":"Won","middleName":"Kyu","lastName":"Lee","suffix":""},{"id":585137203,"identity":"411e9513-8762-4f14-b43a-6fcf8f134956","order_by":5,"name":"Do Yeon Kim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYJACCQa2//X9QAYzA4MFD0TsAEEtzIwzGxgYm4FsErRsOADRwkBQi7x788FbN8rYmI2PH37+uKBCQoa/gfnhB4Yz93BqMTxzLNk65xwPm9mZNMPmGWckeCQOsBlLMNwoxq1lRo6ZdG6bBI/ZDQbDZl4gw4CBwYyB4UMCIS0GEsYz2D9CtbB/w6tFXgKsJcHAQIIHZgsP0JYbuLUY8ID9ciBB4kxO4WwekF8O8xRLJJzBY0t788HbOWUHEvjbj2/4zFNhY8/f3r7xw4djeGw5gCEETAMMuDUAbWnAIzkKRsEoGAWjAAwA78xN11/kOn0AAAAASUVORK5CYII=","orcid":"","institution":"Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea","correspondingAuthor":true,"prefix":"","firstName":"Do","middleName":"Yeon","lastName":"Kim","suffix":""}],"badges":[],"createdAt":"2025-12-17 04:53:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8381576/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8381576/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13019-026-04221-7","type":"published","date":"2026-04-20T15:57:40+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":102180704,"identity":"217a1c9f-96bd-44b4-b9f5-02fd39a4a2f3","added_by":"auto","created_at":"2026-02-09 07:13:34","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":97569,"visible":true,"origin":"","legend":"\u003cp\u003eChest CT sagittal image showing signs of impending rupture of the aortic arch, including an irregular luminal outpouching with a surrounding heterogeneous high-attenuation lesion. The lesion enlarged from 3.5 cm to 4.5 cm in long-axis diameter over two months.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8381576/v1/a59b70d82b4dcf2013e07d18.jpg"},{"id":102180739,"identity":"72ebe487-49d6-4890-88cf-f7bac935185d","added_by":"auto","created_at":"2026-02-09 07:13:45","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":125369,"visible":true,"origin":"","legend":"\u003cp\u003eCreation of a single-fenestrated stent graft using a Valiant Captiva device. A 7-mm fenestration was made approximately 5 mm distal to the proximal edge of the graft using ophthalmic electrocautery. The fenestration was reinforced internally with an EN Snare (Merit Medical, South Jordan, UT, USA) and 5-0 prolene sutures for circumferential marking.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8381576/v1/bd5de6ea65e76fe6b8897541.jpg"},{"id":102180606,"identity":"72c5a09d-72d7-43d8-b34a-3da4e4b6ee2a","added_by":"auto","created_at":"2026-02-09 07:13:17","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":237383,"visible":true,"origin":"","legend":"\u003cp\u003eA: Pre-procedure aortography showing the presence of the lesion. B: Post-procedure aortography demonstrating no endoleak following the intervention.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8381576/v1/827810d8e886e4444208319c.jpg"},{"id":102180714,"identity":"c2f8e631-a7fe-4592-93d1-8ae87e849230","added_by":"auto","created_at":"2026-02-09 07:13:37","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":253111,"visible":true,"origin":"","legend":"\u003cp\u003eA: Postoperative sagittal CT image showing a small non-persistent endoleak. B: 3D reconstructed CT image confirming complete exclusion of the lesion, with resolution of the endoleak on follow-up CT one month later.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8381576/v1/264725828b9523d1ff75e8c5.jpg"},{"id":107928079,"identity":"e3f0be5b-94d4-46e2-a13f-0ab4a12ad7f9","added_by":"auto","created_at":"2026-04-27 16:07:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":863772,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8381576/v1/a8d64454-c150-4ff4-8e00-ec15408a2e3f.pdf"},{"id":102180729,"identity":"324c9fe6-08b4-4635-9b66-6551693f0aa3","added_by":"auto","created_at":"2026-02-09 07:13:42","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":24200308,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplement \u0026nbsp;Video 1 \u003c/strong\u003e: Hybrid Zone 1 Fenestrated TEVAR with PMEG Procedure\u003c/p\u003e","description":"","filename":"SupplementaryPMEGarchcase.mp4","url":"https://assets-eu.researchsquare.com/files/rs-8381576/v1/00ca7eec2e3455ad00f2b032.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"Hybrid Zone 1 TEVAR Using a Single-Fenestrated PMEG After Left Subclavian-to-Left Common Carotid Bypass: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAortic arch disease presents significant challenges due to its intricate anatomy and the necessity to preserve blood flow to the brain and upper extremities. While open surgical replacement has traditionally been seen as the gold standard, arch surgery is highly demanding. It requires extensive surgical exposure, cardiopulmonary bypass, circulatory arrest, and sometimes multiple stages of procedures. Consequently, perioperative morbidity and mortality rates are considerable, especially in elderly or high-risk patients.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eTo mitigate these risks, hybrid arch repair techniques that combine supra-aortic debranching with endovascular stent-grafting have been developed. Concurrently, advancements in endovascular therapy have facilitated the gradual expansion of TEVAR into the arch. However, TEVAR in Zone 1 or Zone 0 is still constrained by the involvement of supra-aortic branches and the lack of widely accessible, dedicated arch devices, resulting in these procedures being considered off-label.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003cp\u003ePMEGs have emerged as a practical and flexible solution in this context. While not yet widely adopted, PMEGs enable the modification of commercially available devices to fit patient-specific arch anatomy when off-the-shelf devices are either unsuitable or unavailable. Initially introduced in the early 2000s for complex abdominal and thoracoabdominal aortic aneurysms, PMEGs have since expanded their application to aortic arch pathology [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTheir value is especially clear in high-risk or emergent situations, such as impending rupture, where the lengthy manufacturing time for custom-made devices makes them impractical.\u003c/p\u003e \u003cp\u003eIn this report, we present a case of single-fenestrated PMEG for Zone 1 TEVAR following a left subclavian artery to left common carotid artery bypass. This hybrid approach maintained cerebral perfusion while effectively excluding an unstable aortic arch lesion.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 75-year-old woman with a history of rectal cancer, treated surgically ten years ago and currently in complete remission, was referred to our department after experiencing chest discomfort for one month. A chest CT performed at an outside hospital revealed signs of impending rupture of the aortic arch (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The CT findings indicated an irregular luminal outpouching of the aortic arch, accompanied by a surrounding heterogeneous high-attenuation lesion that had progressively enlarged from 3.5 cm to 4.5 cm in long-axis diameter over the past two months. No definite mediastinal or pleural fluid collections were observed. The lesion involved the origin of the LSA, and prompting initial assessments that suggested the need for total arch replacement using a frozen elephant trunk technique.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eHowever, both the ascending and descending thoracic aorta were nearly normal in diameter and morphology, making extensive open arch replacement less favorable. The landing zone length at Zone 2 was only 8 mm, which was insufficient for standard TEVAR, while Zone 1 offered a 21-mm proximal landing zone, allowing for the possibility of a hybrid endovascular approach. The diameter of the LCCA measured 6\u0026ndash;7 mm. Due to our limited experience with PMEGs and the technical complexity of multi-fenestrated designs, we decided to implement a single-fenestration PMEG targeting only the LCCA, combined with an LSA-to-LCCA bypass and LSA occlusion as part of a hybrid arch repair strategy. On the back table, we created a single-fenestrated stent graft using a Valiant Captivia device. A 7-mm fenestration was made approximately 5 mm distal to the proximal edge of the graft using ophthalmic electrocautery, and it was reinforced internally with an EN Snare (Merit Medical, South Jordan, UT, USA) and 5\u0026thinsp;\u0026minus;\u0026thinsp;0 prolene sutures for circumferential marking (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). For catheter guidance, we preloaded a 0.018-inch Gradius wire (Asahi Intecc, Aichi, Japan) through a puncture in the device\u0026rsquo;s outer sheath, passed it through the stent graft, and externalized it through the fenestration before resheathing.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eUnder general anesthesia, an incision was made in the left neck, and a left subclavian artery to left common carotid artery (LSA-to-LCCA) bypass was performed using an 8-mm Intergard knitted graft (Abbott Medical, Plymouth, MN, USA). An 8-Fr sheath was then inserted through the graft. The right common femoral artery (CFA) was accessed under ultrasound guidance, and two Pro-Glide Vascular Closure Devices (Abbott Medical, Plymouth, MN, USA) were employed for pre-closure. A 5-French sheath was placed in the left CFA, and the LSA ostium was occluded using a 14-mm Amplatzer vascular plug (Abbott Medical, Plymouth, MN, USA). For distal landing, a 30 \u0026times; 30 \u0026times; 100 mm Valiant Captivia stent graft (Medtronic, Minneapolis, MN, USA) was deployed via the right CFA using a bottom-up approach. A 14-Fr sheath was introduced into the right CFA. Using a through-and-through wire technique between the LCCA bypass graft and the right CFA, the preloaded wire of the PMEG was exteriorized to facilitate selective catheterization of the LCCA. The single-fenestrated PMEG (Valiant Captivia, 34 \u0026times; 34 \u0026times; 100 mm) was deployed with the fenestration precisely aligned to the LCCA ostium. The fenestration was predilated with an 8 \u0026times; 20-mm Mustang balloon (Boston Scientific, Marlborough, MA, USA) at 10 atm. An 8 \u0026times; 27-mm BeGraft covered stent (Bentley InnoMed, Hechingen, Germany) was then delivered from the LCCA into the fenestration, with the proximal portion flared inside the aortic stent graft using high-pressure ballooning up to 20 atm. Completion aortography showed no endoleak (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePostoperative CT scans showed a small, non-persistent type IA or II endoleak that resolved spontaneously by the follow-up CT one month later, confirming complete exclusion of the lesion (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The total operative time was 4 hours and 30 minutes, and the patient was discharged on postoperative day 8 without complications.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAortic arch pathology is one of the most technically challenging areas for endovascular intervention, primarily due to the arch's complex geometry, high hemodynamic forces, and the critical necessity to preserve cerebral perfusion [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough open total arch replacement has traditionally been the standard treatment, the procedure imposes a significant physiological burden\u0026mdash;especially on elderly or high-risk patients\u0026mdash;due to the necessity of cardiopulmonary bypass, circulatory arrest, and extensive surgical exposure.\u003c/p\u003e \u003cp\u003eWhile TEVAR has become a standard therapy for descending thoracic aortic disease, its application in the arch remains limited, particularly in Zone 1 and Zone 0, where current commercially available devices do not have formal instructions for use.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eWith the advancement of endovascular technologies, there has been a growing interest in hybrid strategies and fully endovascular arch repairs. However, the use of proximal arch TEVAR (Zone 1 or Zone 0) is limited by the scarcity of widely available, dedicated branched or fenestrated arch endografts, many of which are still in the investigational stage or approved only for dissection in specific countries. As a result, when open repair presents significant risks and dedicated devices are unavailable, clinicians often resort to hybrid debranching or physician-modified endografts (PMEGs) to establish adequate landing zones while preserving perfusion to the supra-aortic branches. PMEGs were first developed in the early 2000s to address complex abdominal and thoracoabdominal aortic disease, and their application has since expanded to include the aortic arch. Their flexibility and immediate availability make them especially valuable in emergency situations, such as impending ruptures, where rapid clinical deterioration prevents the time needed for manufacturing custom-made devices.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003ePMEGs, while technically demanding\u0026mdash;particularly with multi-fenestration designs\u0026mdash;provide customized device geometry, enhanced sealing zones, and the benefit of avoiding extensive open surgery. In this case, open total arch replacement with a frozen elephant trunk was initially considered due to the lesion's involvement at the origin of the left subclavian artery, which exhibited radiologic signs of impending rupture. However, the ascending and descending thoracic aorta were nearly normal in diameter, and the patient, an elderly individual with a prior oncologic history, was at high risk. These factors made a minimally invasive approach more suitable. The landing zone in Zone 2 was inadequate, offering only an 8-mm seal zone, while Zone 1 presented a more favorable 21-mm proximal landing zone. This anatomical configuration strongly supported the choice of a Zone 1 hybrid TEVAR with carotid revascularization. Additionally, considering the operator\u0026rsquo;s limited prior experience with PMEGs, a single-fenestration design was deemed more technically reliable than a two-fenestration configuration. This further reinforced the decision to proceed with a Zone 1 hybrid TEVAR combined with an LSA-to-LCCA bypass, simplifying the procedure while ensuring technical success.\u003c/p\u003e \u003cp\u003ePMEGs provide several advantages in specific cases: they enable personalized alignment with branch vessels, create better seal zones than scallops or chimney techniques, and reduce the morbidity associated with extensive open repairs.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] However, concerns persist about their durability, the risk of endoleak, and the technical challenges associated with back-table modifications, especially in multi-fenestrated configurations.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] In this case, a single fenestration was selected to reduce procedural complexity while ensuring sufficient cerebral perfusion through the LCCA. The preloaded wire strategy enabled accurate alignment of the fenestration.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] A small early Type IA or II endoleak was observed on postoperative imaging but resolved spontaneously by the one-month follow-up CT. This finding aligns with previous PMEG reports, which have shown low rates of persistent endoleak when there is adequate apposition between the fenestration and the bridging stent.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] In TEVAR procedures conducted in Zone 2 or more proximal segments, it is crucial to consider the risk of retrograde type A dissection. This complication has been reported in about 2.5% of cases and carries a mortality rate of up to 37%, especially when using devices with a free-flow segment. Therefore, careful planning and device selection are essential to minimize this risk.\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] The patient had a smooth recovery and was discharged on postoperative day 8, illustrating the feasibility and safety of this approach for carefully selected patients. This case underscores the significance of personalized treatment planning in arch pathology, particularly when the anatomy is suitable for an endovascular-first strategy but dedicated devices are scarce. A hybrid repair combined with a single-fenestrated PMEG offers a valuable alternative for Zone 1 lesions in high-risk patients.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe use of single-fenestrated PMEG for Zone 1 TEVAR, along with a bypass from the LSA to the LCCA, offers an effective and less invasive treatment for complex aortic arch lesions in elderly, high-risk patients. This approach ensures secure proximal sealing, maintains cerebral perfusion, and successfully excludes the diseased segment of the arch without significant complications. In situations where dedicated arch devices are unavailable or used off-label, a PMEG-based hybrid repair can be a practical and safe option, provided that the anatomical conditions are suitable and careful planning is executed.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTEVAR : Thoracic endovascular aortic repair\u003c/p\u003e\n\u003cp\u003ePMEGs : Physician-modified endografts\u003c/p\u003e\n\u003cp\u003eLSA : Left subclavian artery\u003c/p\u003e\n\u003cp\u003eLCCA : Left common carotid artery\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCT : Computed tomography\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis manuscript was proofread and edited by the professional English editors at HARRISCO.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDYK and SBH contributed to the study design, research, and manuscript writing. JL, DHL, WKL, and JSY were involved in manuscript editing and conducting the research. DYK performed the surgery and procedure, with DHL and WKL assisting during the procedure. All authors have read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work received no funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analyzed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent for participation in this study was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent was obtained from the patient for publishing this report and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests relevant to this report to disclose.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLodo V, Centofanti P. Current techniques of repair of aortic arch pathologies and the role of the aortic team. Indian J Thorac Cardiovasc Surg. 2024;40(4):451\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXydas S, et al. Hybrid repair of aortic arch aneurysms: a comprehensive review. J Thorac Dis. 2017;9(Suppl 7):S629\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGao X, et al. Efficacy and safety of debranching technique with zone 1 thoracic endovascular aortic repair in high-risk patients with distal aortic arch lesions. J Cardiothorac Surg. 2025;20(1):239.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhu J, et al. Fenestrated Thoracic Endovascular Aortic Repair Using Physician-Modified Stent Grafts (PMSGs) in Zone 0 and Zone 1 for Aortic Arch Diseases. Cardiovasc Intervent Radiol. 2019;42(1):19\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanaoka Y, et al. Technical challenges in endovascular repair of complex thoracic aortic aneurysms. Ann Vasc Dis. 2012;5(1):21\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRylski B. Endovascular approach to complex aortic arch pathologies: state of the art. Kardiochir Torakochirurgia Pol. 2016;13(1):1\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHalbert S, et al. Endovascular Repair of Zone 0 Ascending Aortic Aneurysm: A Review of Current Knowledge and Developing Technology. Aorta (Stamford). 2024;12(1):13\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcClure RS, et al. Zone 0 Aortic Arch Reconstruction Using the RelayBranch Thoracic Stent Graft. CJC Open. 2021;3(10):1307\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJędrzejczak T, et al. Physician-modified endograft in ruptured aortic arch. Postepy Kardiol Interwencyjnej. 2022;18(1):70\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSolano A, et al. Physician Modified Endograft for Ruptured Dissecting Aortic Arch Aneurysm. Vasc Endovascular Surg. 2024;58(8):876\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee KB, et al. Early Results and Feasibility of Total Endovascular Aortic Arch Repair Using 3-Vessel Company-Manufactured and Physician-Modified Stent-Grafts. J Endovasc Ther. 2024;31(6):1197\u0026ndash;207.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKansagra K, et al. Advanced endografting techniques: snorkels, chimneys, periscopes, fenestrations, and branched endografts. Cardiovasc Diagn Ther. 2018;8(Suppl 1):S175\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoqaddam M, et al. Short-term results of fenestrated physician-modified endografts for type1a endoleak after conventional thoracic endovascular aortic repair. JTCVS Tech. 2024;25:8\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCanaud L, et al. Total Arch Thoracic Endovascular Aortic Repair Using Double Fenestrated Physician-Modified Stent-Grafts: 100 Patients. J Endovasc Ther. 2024;31(1):89\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuistra EWM et al. Preloaded Physician-Modified Thoracic Endovascular Aortic Repair to Achieve Left Subclavian Artery Fenestration Alignment in Zone 2. J Endovasc Ther, 2025: p. 15266028251344882.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChassin-Trubert L, et al. Double fenestrated physician-modified stent-grafts for total aortic arch repair in 50 patients. J Vasc Surg. 2021;73(6):1898. \u0026ndash;1905.e1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWen Q, et al. Physician Modified Fenestrated Endografts for Endovascular Aortic Arch Repair in Zone 0. Eur J Vasc Endovasc Surg. 2024;68(2):190\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen Y et al. Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis. J Am Heart Assoc, 2017. 6(9).\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":"Aortic arch disease, Zone 1 TEVAR, Physician-modified endograft, Hybrid arch repair, Fenestrated stent graft","lastPublishedDoi":"10.21203/rs.3.rs-8381576/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8381576/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAortic arch disease poses significant challenges because of its complex anatomy and the necessity to maintain blood flow to the brain and upper extremities. Traditional surgical repair involves considerable perioperative risks, especially for elderly or high-risk patients. Meanwhile, thoracic endovascular aortic repair (TEVAR) in the aortic arch faces limitations due to the involvement of supra-aortic vessels and the absence of specialized devices. As a solution, physician-modified endografts (PMEGs) have emerged as a viable option to facilitate TEVAR in difficult arch segments.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e \u003cp\u003eA 75-year-old woman with a history of rectal cancer presented with chest discomfort. Imaging revealed a 4.5-cm lesion in the aortic arch that involved the origin of the left subclavian artery (LSA) and showed signs of impending rupture. Due to the limited proximal landing zone at Zone 2 (8 mm) and the suitable anatomy at Zone 1 (21 mm), a hybrid approach was planned. A single-fenestrated PMEG targeting the left common carotid artery (LCCA) was created on the back table, with a preloaded wire to ensure precise alignment of the fenestration. The procedure also included a bypass from the LSA to the LCCA. The PMEG was deployed through femoral access, and the fenestration was bridged with a covered stent graft. Postoperative imaging revealed a small transient endoleak that resolved spontaneously during a follow-up computed tomography (CT) scan one month later. The patient recovered well and was discharged on postoperative day 8.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe combination of single-fenestrated PMEG with LSA-to-LCCA bypass offers a safe and effective hybrid strategy for Zone 1 TEVAR in high-risk patients. This method ensures secure proximal sealing, maintains cerebral perfusion, and successfully excludes the diseased arch segment. PMEG-based hybrid repair serves as a viable alternative when dedicated arch devices are either unavailable or used off-label, especially in anatomically favorable cases.\u003c/p\u003e","manuscriptTitle":"Hybrid Zone 1 TEVAR Using a Single-Fenestrated PMEG After Left Subclavian-to-Left Common Carotid Bypass: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-09 07:12:31","doi":"10.21203/rs.3.rs-8381576/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-05T07:28:14+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-14T01:19:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-11T03:35:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-10T18:19:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"19660584566901159086881052822917745229","date":"2026-02-05T13:31:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"20973339936917492567322444032538879415","date":"2026-02-05T12:47:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-03T15:01:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"10467287743680270854861244500631593937","date":"2026-02-03T13:57:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"217703945662130255266270458439535591978","date":"2026-02-03T13:04:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-03T11:47:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-19T05:24:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-19T05:21:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-12-17T04:37:10+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":"61c9c5d7-167d-48e7-85f0-b3b33fc37bd1","owner":[],"postedDate":"February 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T16:05:08+00:00","versionOfRecord":{"articleIdentity":"rs-8381576","link":"https://doi.org/10.1186/s13019-026-04221-7","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2026-04-20 15:57:40","publishedOnDateReadable":"April 20th, 2026"},"versionCreatedAt":"2026-02-09 07:12:31","video":"","vorDoi":"10.1186/s13019-026-04221-7","vorDoiUrl":"https://doi.org/10.1186/s13019-026-04221-7","workflowStages":[]},"version":"v1","identity":"rs-8381576","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8381576","identity":"rs-8381576","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}