Physician-modified Endograft with Left Subclavian Artery Fenestration for Ruptured Type B Aortic Dissection

A 56-year-old male patient was transferred to our institution with acute chest and back pain and deteriorating vital signs for 3 days. Emergent computed tomography angiography (CTA) revealed ruptured type B aortic dissection with large left hemothorax. The dissection extended into the left subclavian artery (LSA). Immediate endovascular aortic repair with LSA coverage to extend the proximal landing zone was planned. Fenestrated thoracic endovascular repair (fTEVAR) was performed using a physician-modified endograft (PMEG) to maintain LSA perfusion. The thoracic endograft was modified on a back table while anesthesia was given, and arterial accesses were acquired. FTEVAR was performed smoothly without any complication. Completion angiogram showed no evidence of endoleak or active bleeding. Chest tube was then placed, and the left lung gradually expanded. Postoperative hospital courses were uneventful. Follow-up CTA showed the thoracic endograft and the LSA stent were in good position, and the rupture thoracic aorta was completely sealed. Chest tube was removed on postoperative day (POD) 7. He was discharged home on POD 20 without any complications. Detailed techniques of PMEG for LSA fenestration are described.