A Novel Approach to Thoracic Endovascular Aortic Repair Using “Zone 1.5” Deployment of the Gore Thoracic Branched Endoprosthesis Device

Sep 29, 2026

A novel “zone 1.5” strategy for thoracic endovascular aortic repair is proposed to improve safety when standard zone 2 or 1 repairs are not feasible. The approach covers distally to the innominate artery, uses the device’s subclavian branch, and adds a left subclavian-to-left carotid bypass to maintain carotid perfusion. In a registry of 75 patients, 3 patients underwent this repair with favorable outcomes. The strategy is positioned as a safer alternative to zone 0 when needed.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages7

Reading Time18 min

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ABSTRACT

Endovascular treatment background and rationale

Anatomical criteria and device deployment requirements

Escalation to zone 1 and zone 0 when zone 2 is not feasible

Methods for the “zone 1.5” deployment

From the Society for Clinical Vascular Surgery A novel approach to thoracic endovascular aortic repair using “zone 1.5” deployment of the Gore thoracic branched endoprosthesis device Keyuree Satam, MD, MHS,a Arash Fereydooni, MD, MS, MHS,a Sabina Sorondo, MD,a Pauline Berens, MD,a and Jason T. Lee, MD,a, b Palo Alto, CA ABSTRACT The TAG thoracic branched endoprosthesis is Food and Drug Administration approved for zone 2 repair with a branch to the left subclavian artery. Zone 1 repairs require a carotid-subclavian bypass, and zone 0 may necessitate full arch debranching with higher stroke risk. We propose a “zone 1.5” approach: coverage distal to the innominate artery, subclavian branch via the device, and left subclavian-to-left carotid bypass to perfuse the carotid. Among 75 thoracic branched endoprosthesis patients in our registry, three underwent this “zone 1.5” repair with favorable outcomes. This strategy may offer a safer alternative to zone 0 when standard zone 2 or 1 repairs are not feasible. (J Vasc Surg Cases Innov Tech 2026;12:102026 . ) Keywords: Thoracic aneurysm; Thoracic dissection; Thoracic branched endoprosthesis; TEVAR; Endovascular Endovascular treatment of thoracic aortic disease that requires proximal seal in zone 2 between the takeoff of the left subclavian artery (LSCA) and the left common carotid artery historically required debranching with carotid-subclavian bypass, followed by thoracic endovascular aortic repair (TEVAR) over the LSCA. However, the development and clinical trials of single-branched thoracic devices including the Nexus aortic arch stent graft system (Endospan Ltd), the Valiant Mona LSCA graft (Medtronic), and the TAG Thoracic Branched Endoprosthesis (TBE) (W. L. Gore) have allowed for endovascular preservation of the left subclavian with an integrated branch.1 The TBE has the most published experience and was recently Food and Drug Administration approved in 2022. A preapproval study by Dake et al2 found low mortality, promising 1-year patency, and low rates of reinterventions and endoleaks, deeming the product safe and effective. A number of anatomic criteria must be satisfied for TBE deployment in zone 2 (Fig 1) . The device is available From the Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford Medicine,a and the Baszucki Family BioBank, Division of Vascular Surgery, Stanford University School of Medicine. b Presented at the Fifty-second Annual Meeting of the Society for Clinical Vascular Surgery, Austin, Tex, March 30-April 3, 2025. Correspondence: Keyuree Satam, MD, MHS, Division of Vascular Surgery, Stanford Medicine, 780 Welch Rd, CJ350, Palo Alto, CA 94304 (e-mail: ksatam@ [outlook.com](outlook.com) ) . The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 2468-4287 © 2025 The Authors. Published by Elsevier Inc. on behalf of Society for Vascular Surgery. This is an open access article under the CC BY-NC-ND license ([http://](http://)[ ](http://)[creativecommons.org/licenses/by-nc-nd/4.0/](creativecommons.org/licenses/by-nc-nd/4.0/)) . [https://doi.org/10.1016/j.jvscit.2025.102026](https://doi.org/10.1016/j.jvscit.2025.102026) with 8- and 12-mm portals that accommodate size branch diameters of 8 to 17 mm and 15 to 20 mm, respectively. A TBE with 8-mm portal requires 15-20 mm of proximal landing and a 12-mm portal TBE requires 34-36 mm . This length (B) is measured from the distal edge of the left common carotid to the distal edge of the LSCA.3 If there is insufficient distance or seal for a zone 2 TBE, the graft may need to be shifted proximally to zone 1, with branch placement in the left common carotid and carotid-subclavian bypass. The same proximal seal requirements must be satisfied from the distal edge of the innominate to the distal edge of t

FAQs

What problem does the “zone 1.5” approach address in thoracic branched endoprosthesis repair?

It addresses situations where standard zone 2 or zone 1 repairs cannot achieve adequate proximal sealing or landing length, without needing the more extensive zone 0 total debranching.

How is the “zone 1.5” deployment configuration constructed anatomically?

It places the TBE branch in the left subclavian artery while maintaining proximal seal in zone 1, combined with a left subclavian-to-carotid bypass to perfuse the carotid.

What outcomes were reported for patients treated with the “zone 1.5” approach?

Among 75 thoracic branched endoprosthesis patients in the registry, 3 underwent “zone 1.5” repair, and outcomes were favorable according to the abstract.

Sep 29, 2026

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