Complementary anatomy-driven strategies of unibody single-branched and physician-modified endografts with selective bridging stent omission in Zone 2 TEVAR

To evaluate the safety and efficacy of the Castor unibody single-branched stent-graft versus physician-modified endograft (PMEG) for left subclavian artery (LSA) revascularization during zone 2 thoracic endovascular aortic repair (TEVAR) and to assess the feasibility of selectively omitting the bridging stent in the PMEG technique. This retrospective study analyzed 131 patients undergoing Zone 2 TEVAR with LSA revascularization (2022.1–2023.12). Patients were assigned to the Castor ( n = 47) or PMEG ( n = 84). The PMEG cohort was stratified into bridging-stented ( n = 57) and non-bridging-stented ( n = 27) subgroups. Primary endpoints included 30-day and follow-up rates of all-cause mortality, aortic-related mortality, and major complications. Initial technical success was achieved in 121 of 131 patients (92.4%), and final technical success was achieved in 131 of 131 patients (100%) after bailout procedures. Initial technical success was similar between Castor and PMEG groups (95.7% vs. 90.5%, p = 0.330). No patient required conversion to open repair after an unsuccessful endovascular procedure. Both groups had 0% 30-day all-cause mortality and major adverse events. The Castor stent was used more for greater curvature lesions, while PMEG was preferentially used for lesser curvature involvement (83.0% vs. 90.5%, p < 0.001). The 10 intraoperative technical failures were all managed successfully during the index procedure, and none of these specific failures required follow-up reintervention. During follow-up, two separate new events required reintervention (overall 1.5%, 2/131); these events were distinct from the 10 intraoperative technical failures and occurred in different patients: one patient in the Castor group underwent distal extension stent-graft placement for a new distal dissection, and one patient in the PMEG bridging-stented subgroup underwent coil embolization for a type IIa endoleak. Within the PMEG cohort, the non-bridging-stented subgroup had a higher proportion of patients treated for aortic dissection (81.5% vs. 56.1%, p = 0.024) and a shorter procedure time (60.0 vs. 80.0 min, p = 0.020), with no endoleaks, branch occlusions, or aortic-related deaths during follow-up. The Castor single-branched stent-graft and PMEG are complementary, anatomy-specific strategies. Both provided acceptable midterm outcomes within their respective anatomical niches. In highly selected patients, primarily those with aortic dissection and favorable seal zones and arch anatomy, selective omission of the bridging stent during PMEG appeared feasible with acceptable midterm outcomes; however, these findings are preliminary and do not establish safety in patients outside these criteria. Given the small non-bridging-stented subgroup and limited follow-up, these results remain hypothesis-generating and require prospective validation with long-term imaging.