Custom-made left subclavian artery branch stent graft: experience of a single center

Endovascular strategies represent minimally invasive and valid alternatives to surgical debranching for left subclavian artery (LSA) revascularization in Zone 2 thoracic endovascular aneurysm repair (TEVAR). This study aims to review the literature on the use of Cook Medical Custom-Made Devices (CMDs) incorporating an inner retrograde LSA branch and report a single-center experience with this approach.

A retrospective analysis was conducted on patients treated in a single high-volume aortic referral center between November 2023 and August 2025. Patients included underwent Zone 2 TEVAR using a CMD stent graft with a single retrograde inner LSA branch (Cook Medical, Bjaeverskov, Denmark). Literature on CMDs for LSA preservation was also reviewed to contextualize findings.

Sixty patients underwent LSA revascularization in Zone 2 TEVAR, including 28 carotid-subclavian bypasses, eight in-situ fenestrations, 16 off-the-shelf branched devices, and eight Cook Medical CMDs, of which seven single LSA inner branches and one was incorporated with a fenestration. All LSA branch CMD cases were elective, with a 100% technical success rate. Two early reinterventions were performed: one for a persistent Type Ia endoleak managed with proximal coil embolization, and another for a Type IIIc endoleak treated by relining the LSA stent graft. One postoperative death occurred due to cerebral embolization. There were no instances of branch occlusion, device migration, or target vessel stenosis during a short-term follow-up.

CMD LSA branch endografts represent a valid solution for complex Zone 2 aortic pathology, offering full endovascular repair with individualized anatomical adaptation over off-the-shelf solutions. Our outcomes demonstrate early feasibility with high technical success; however, further studies with larger cohorts and long-term follow-ups are warranted.