Hybrid Zone 1 TEVAR Using a Single-Fenestrated PMEG After Left Subclavian-to-Left Common Carotid Bypass: A Case Report

Background Aortic arch disease poses significant challenges because of its complex anatomy and the necessity to maintain blood flow to the brain and upper extremities. Traditional surgical repair involves considerable perioperative risks, especially for elderly or high-risk patients. Meanwhile, thoracic endovascular aortic repair (TEVAR) in the aortic arch faces limitations due to the involvement of supra-aortic vessels and the absence of specialized devices. As a solution, physician-modified endografts (PMEGs) have emerged as a viable option to facilitate TEVAR in difficult arch segments. Case presentation A 75-year-old woman with a history of rectal cancer presented with chest discomfort. Imaging revealed a 4.5-cm lesion in the aortic arch that involved the origin of the left subclavian artery (LSA) and showed signs of impending rupture. Due to the limited proximal landing zone at Zone 2 (8 mm) and the suitable anatomy at Zone 1 (21 mm), a hybrid approach was planned. A single-fenestrated PMEG targeting the left common carotid artery (LCCA) was created on the back table, with a preloaded wire to ensure precise alignment of the fenestration. The procedure also included a bypass from the LSA to the LCCA. The PMEG was deployed through femoral access, and the fenestration was bridged with a covered stent graft. Postoperative imaging revealed a small transient endoleak that resolved spontaneously during a follow-up computed tomography (CT) scan one month later. The patient recovered well and was discharged on postoperative day 8. Conclusions The combination of single-fenestrated PMEG with LSA-to-LCCA bypass offers a safe and effective hybrid strategy for Zone 1 TEVAR in high-risk patients. This method ensures secure proximal sealing, maintains cerebral perfusion, and successfully excludes the diseased arch segment. PMEG-based hybrid repair serves as a viable alternative when dedicated arch devices are either unavailable or used off-label, especially in anatomically favorable cases.