Thoracic Endovascular Aortic Repair for Challenging Aortic Arch Diseases Using Fenestrated Stent Grafts From Zone 0 Yoshihiko Kurimoto, MD, PhD, Ryushi.

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Thoracic Endovascular Aortic Repair for Challenging Aortic Arch Diseases Using Fenestrated Stent Grafts From Zone 0 Yoshihiko Kurimoto, MD, PhD, Ryushi Maruyama, MD, PhD, Kousuke Ujihira, MD, Naritomo Nishioka, MD, Kousei Hasegawa, MD, Yutaka Iba, MD, Eiichiro Hatta, MD, PhD, Akira Yamada, MD, PhD, Katsuhiko Nakanishi, MD, PhD The Annals of Thoracic Surgery Volume 100, Issue 1, Pages 24-33 (July 2015) DOI: 10.1016/j.athoracsur.2015.01.071 Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 (A) Computed tomographic images regarding a proximal neck (PN) length. Although the PN length at the lesser curvature of the aortic arch is almost zero, this case was used in the present study because there is a PN length between the left common carotid artery and aortic arch aneurysm, a. The PN length at the greater and lesser curvature of the aortic arch is more than 15 mm. This type of aneurysm has been treated using a conventional non-fenestrated stent graft, which means that this case was not included in the present study, b. (B) Computed tomographic images after TEVAR. The case on the left, a, was treated using a fenestrated stent graft. The case on the right, b, which was not a subject in this study, was treated using a Valiant (Medtronic, Inc) modified to make a fenestration to preserve the left subclavian artery. The Annals of Thoracic Surgery 2015 100, 24-33DOI: (10.1016/j.athoracsur.2015.01.071) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Illustration of a semi-custom-made fenestrated stent graft. The white arrow shows a fenestration made to preserve the left common carotid artery. Generally, both the second and proximal section of the third (white arrow) fenestrations preserve the brachiocephalic artery (BCA). A proximal fenestration was made to prevent the possibility of an unintentional distal migration of a stent graft covering BCA. The Annals of Thoracic Surgery 2015 100, 24-33DOI: (10.1016/j.athoracsur.2015.01.071) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 A schema expressing the values used in Table 2. (Left) (1) Length of a proximal neck (PN) between the left common carotid artery and the aneurysm. (2) Length of the PN at the great curvature. (3) Length of the PN at the lesser curvature. (Right) (4) Radius of the lesser curvature at PN. The Annals of Thoracic Surgery 2015 100, 24-33DOI: (10.1016/j.athoracsur.2015.01.071) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 (A) A schema showing the left subclavian artery (LSA) management techniques in this study. The LSA, located very close to the left common carotid artery (LCCA), was partially preserved in 7 cases by the same fenestration used to maintain blood flow into the LCCA. (B) A histogram outlining the distribution of a distal end of placed stent grafts. The 3 sections in black indicate the patients experiencing spinal cord ischemia complications. The Annals of Thoracic Surgery 2015 100, 24-33DOI: (10.1016/j.athoracsur.2015.01.071) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Survival and aorta-related event-free curves after thoracic endovascular aortic repair using a fenestrated stent graft. The black line and gray dotted line indicate overall survival rates and aorta-related event-free rates after discharge, respectively. The Annals of Thoracic Surgery 2015 100, 24-33DOI: (10.1016/j.athoracsur.2015.01.071) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Computed tomographic images before and after thoracic endovascular aortic repair (TEVAR) for an extended thoracic aortic aneurysm. The (A) descending thoracic aortic aneurysm combined with the aortic arch aneurysm, that (C, D) ruptured into the left pleural cavity was treated by TEVAR using a fenestrated stent graft and conventional non-fenestrated stent grafts. The (B) brachiocephalic and left common carotid arteries were well preserved and the left subclavian artery was simply covered by a non-fenestrated stent graft without any reconstruction. The Annals of Thoracic Surgery 2015 100, 24-33DOI: (10.1016/j.athoracsur.2015.01.071) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions