Treatment of a Dissecting Thoracic Aortic Aneurysm with Aberrant Right Subclavian Artery Using Physician-Modified Endovascular Graft

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Dissecting thoracic aortic aneurysm (Stanford B, DeBakey IIIb) with aberrant right subclavian artery (ARSA) and ascending aortic dilation (n=1). Intervention: Two-stage hybrid repair: ascending-to-arch graft replacement followed by TEVAR with a physician-modified endovascular graft (PMEG) fenestrated for ARSA. Primary outcome: Preservation of ARSA blood flow and absence of endoleak on contrast-enhanced CT.

Q: What does this research mean for the field?

A staged approach combining open ascending graft replacement and TEVAR with a fenestrated physician-modified endovascular graft safely treats a dissecting thoracic aortic aneurysm while preserving aberrant right subclavian artery perfusion without endoleak. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Ayako Nagasawa; Ryo Yamaguchi; Takao Miki; Shuichi Okonogi; Kiyomitsu Yasuhara; Satoshi Ohki

doi:10.4326/jjcvs.55.267

September 15, 2026Japanese Journal of Cardiovascular SurgeryOpen Access

Treatment of a Dissecting Thoracic Aortic Aneurysm with Aberrant Right Subclavian Artery Using Physician-Modified Endovascular Graft

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Why the study?

One-stage prosthetic graft replacement via left thoracotomy was considered high-risk for an older dialysis patient with CFS 5, and preservation of the aberrant right subclavian artery (ARSA) was needed for potential future shunt creation.

Does a staged hybrid approach combining ascending/arch graft replacement and thoracic endovascular aortic repair using a physician-modified endovascular graft (PMEG) preserve aberrant right subclavian artery blood flow without endoleak in a frail, hemodialysis-dependent patient with a dissecting thoracic aortic aneurysm?

Key Points

To describe a two-stage hybrid surgical strategy for treating a dissecting thoracic aortic aneurysm complicated by an aberrant right subclavian artery in a high-risk patient.
Treated a 76-year-old woman on maintenance hemodialysis (Clinical Frailty Scale 5) presenting with ascending aorta dilation and a descending dissecting thoracic aortic aneurysm.
Conducted stage one graft replacement from the ascending aorta to the bifurcation of the aberrant right subclavian artery (ARSA) via median sternotomy using cardiopulmonary bypass and selective cerebral perfusion.
Performed stage two thoracic endovascular aortic repair (TEVAR) 30 days later using a physician-modified endograft (PMEG) with a 9 mm by 14 mm fenestration tailored to preserve the ARSA.
Both procedures were completed without major complications, with blood loss of 385 ml in stage one and 30 ml in stage two.
Follow-up contrast-enhanced computed tomography at 5 days and 1 year postoperatively confirmed patent ARSA blood flow without endoleak.
The patient maintained hemodialysis access without disruption and was discharged home 18 days after the second-stage repair.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

Does a staged hybrid approach combining ascending/arch graft replacement and thoracic endovascular aortic repair using a physician-modified endovascular graft (PMEG) preserve aberrant right subclavian artery blood flow without endoleak in a frail, hemodialysis-dependent patient with a dissecting thoracic aortic aneurysm?

P

Population

1 elderly female (age 76) on chronic hemodialysis with a dissecting thoracic aortic aneurysm and aberrant right subclavian artery, followed for 1 year postoperatively.

I

Intervention

Staged hybrid surgical repair: Stage 1 involved median sternotomy and ascending/arch aortic graft replacement (using a 24 mm 4-branched J-graft) from the ascending aorta to just proximal to the ARSA bifurcation under cardiopulmonary bypass and selective cerebral perfusion. Stage 2 (performed 30 days later) involved thoracic endovascular aortic repair (TEVAR) via right femoral artery exposure using a distal Zenith Alpha stent graft and a proximal 34 mm Zenith Alpha physician-modified endovascular graft (PMEG) featuring a 9 mm × 14 mm fenestration created between the 2nd and 3rd stents aligned to preserve ARSA perfusion.

O

Outcome

Preservation of ARSA blood flow and absence of endoleak assessed by contrast-enhanced computed tomography (CT) at postoperative day 5 and 1 year after the second-stage procedure.surrogate

Limitations

Single-patient case report
Lack of large-scale comparative studies evaluating physician-modified endovascular grafts (PMEG) for aortic disease

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Implication

A two-stage hybrid repair combining ascending/arch graft replacement and fenestrated physician-modified endovascular graft (PMEG) TEVAR safely treated a dissecting thoracic aortic aneurysm while preserving aberrant right subclavian artery perfusion in a frail hemodialysis patient.

Abstract

症例は76歳女性．偶発的に解離性胸部大動脈瘤を指摘され当院を受診した．精査すると左鎖骨下動脈分岐末梢側に異所性右鎖骨下動脈（ARSA）を認めた．上行大動脈拡張を伴う下行の解離性大動脈瘤に対して2期的（人工血管置換術＋胸部ステントグラフト内挿術）に治療を行った．まず，胸骨正中切開で，人工心肺使用で脳分離循環を併用し上行大動脈からARSA分岐直前までを人工血管置換した．その後，ARSAに合わせて開窓したPhysician-Modified Endovascular Graft （PMEG）を使用して胸部ステントグラフト内挿術（TEVAR）を施行した．術後経過はおおむね良好で，術後造影CTでARSAの血流は温存されエンドリークを認めず，合併症なく自宅退院となった．高齢の透析患者でCFS5であったため，左開胸を伴う1期的な人工血管置換術は高リスクと判断し，2期的に手術を行った．今後のシャント作製などを考慮しARSAは開窓したPMEGを使用して温存し，安全に治療を終了することができた．

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Cite This Study

Nagasawa et al. (2026) conducted a case report in Dissecting thoracic aortic aneurysm (Stanford B, DeBakey IIIb) with aberrant right subclavian artery (ARSA) and ascending aortic dilation (n=1). Two-stage hybrid repair: ascending-to-arch graft replacement followed by TEVAR with a physician-modified endovascular graft (PMEG) fenestrated for ARSA was evaluated on Preservation of ARSA blood flow and absence of endoleak on contrast-enhanced CT.

synapsesocial.com/papers/6af0e999de503f3774140a4e https://doi.org/10.4326/jjcvs.55.267

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Treatment of a Dissecting Thoracic Aortic Aneurysm with Aberrant Right Subclavian Artery Using Physician-Modified Endovascular Graft

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Treatment of a Dissecting Thoracic Aortic Aneurysm with Aberrant Right Subclavian Artery Using Physician-Modified Endovascular Graft

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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