Transfemoral Bridging Stent-Graft Delivery in Zone 0 Endovascular Arch Repair With Triple-Fenestrated Endograft

Zone 0 thoracic endovascular aortic repair (TEVAR) remains technically demanding because of limited proximal landing zones and the need to preserve all supra-aortic branches. Conventional strategies-including branched endografts, chimney or snorkel techniques, and hybrid repairs-have been associated with increased risks of stroke, retrograde type A dissection, and perioperative mortality. We describe a technique using a physician-modified triple-fenestrated endograft with transfemoral delivery of all bridging covered stents (BCSs) to the brachiocephalic, left common carotid, and left subclavian arteries. Cervical and brachial access was used solely for angiography and minimal catheter manipulation, thereby aiming to reduce cerebral embolization risk. A 71-year-old man with a history of coronary artery bypass surgery and reduced left ventricular ejection fraction (31%) presented with fever. Imaging revealed a dissecting aortic aneurysm confined to the arch. Blood cultures were positive for methicillin-susceptible Staphylococcus aureus. After intravenous antibiotic therapy, cultures became negative; however, the aneurysm enlarged. Given the high surgical risk, TEVAR was selected. All BCSs were delivered transfemorally without complications. Postoperative and 1-year follow-up imaging showed no endoleak and a reduction in aneurysm size. This approach may offer a less invasive and embolic risk-reducing option for managing arch pathology in high-risk patients.