In situ fenestration of a frozen elephant trunk prosthesis to recanalize the left subclavian artery

Sep 28, 2026

Uploaded by Oliver

Maintaining left subclavian artery (LSA) patency is critical to prevent spinal cord ischemia during extensive aortic coverage. This report describes an in situ fenestration performed on a zone 2 frozen elephant trunk graft to reestablish native LSA perfusion after prior LSA bypass occlusion. Fenestration used the electrified wire technique, followed by balloon-expandable covered stent implantation and distal thoracic extensions, with postoperative imaging confirming durable LSA patency.

LanguageEnglish

CategoryHealthcare

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Abstract

Surgical Technique

Case Report

Technique

In situ fenestration of a frozen elephant trunk prosthesis to recanalize the left subclavian artery George Apostolidis, MD, MSc,a Petroula Nana, PhD,a Daour Yousef al Sarhan, MD,a Lennart Bax, MD,b Tilo Kölbel, PhD,a and Giuseppe Panuccio, PhD,a Hamburg, Germany ABSTRACT Maintaining left subclavian artery (LSA) patency is essential for preventing spinal cord ischemia before extensive aortic coverage. We present a case of in situ fenestration on a zone 2 frozen elephant trunk graft to restore the native LSA perfusion after a prior LSA bypass occlusion. Fenestration was performed using the electrified wire technique, followed by balloon-expandable covered stent implantation. The procedure was completed with distal thoracic extensions. The postoperative imaging confirmed LSA patency. This approach offers a feasible, reproducible solution for selected patients requiring LSA recanalization after frozen elephant trunk. (J Vasc Surg Cases Innov Tech 2026;12:102059 . ) Keywords: Electrified wire technique; Endovascular aortic repair; Frozen elephant trunk; In situ fenestration; Left subclavian artery Frozen elephant trunk (FET) represents the indicated approach in fit patients with aortic arch and proximal descending aorta diseases.1,2 The simplified Zone 2 FET has been associated with reduced cerebrovascular morbidity and mortality compared with Zone 3 FET.3,4 During Zone 2 FET, the revascularization of the left subclavian artery (LSA) is performed through a carotid subclavian or bypass between the LSA and aortic graft.4 Limited data report an occlusion rate of 6% following Zone 2 FET.5 LSA occlusion management may be conservative or interventional, depending on the clinical relevance; LSA revascularization using bypass, transposition, or in situ fenestration is selected most commonly to prevent spinal cord ischemia (SCI) and preserve upper limb perfusion.1 Herein, we present an in situ fenestration for LSA recanalization using the electrified wire technique after a zone 2 FET in a patient needing extensive aortic coverage. SURGICAL TECHNIQUE Case report. A 64-year-old male presented with diffuse abdominal tenderness 3 years after a zone 2 FET (Thoraflex Hybrid; Terumo Aortic) combined with ligation and From the German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburga; and the Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart and Vascular Centre Hamburg. b Correspondence: George Apostolidis, MD, MSc, German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, Martinistrasse 52, Hamburg 20251, Germany (e-mail: apgiorgos@ [yahoo.gr](yahoo.gr)) . 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 Author(s) . Published by Elsevier Inc. on behalf of Society for Vascular Surgery. This is an open access article under the CC BY license ([http://creativecommons.org/licenses/by/4.0/](http://creativecommons.org/licenses/by/4.0/)) . [https://doi.org/10.1016/j.jvscit.2025.102059](https://doi.org/10.1016/j.jvscit.2025.102059) revascularization of the LSA via a supraclavicular bypass (Fig 1, A) . An emergent computed tomography angiography revealed a 78-mm type II thoracoabdominal aneurysm (Fig 1, A) and a previously unknown occlusion of the LSA bypass (Fig 1, B and C) . Given his symptoms and multimorbid profile, including heart insufficiency and chronic kidney disease, an urgent endovascular approach, with extensive aortic coverage, was decided, including LSA revascularization for SCI prevention. The native LSA was chosen for recanalization over the existent bypass, due to its lower thrombotic burden and risk of distal embolization and reocclusion. Written informed consent was obtained; anonymized d

FAQs

Why is left subclavian artery patency important before extensive aortic coverage?

Maintaining LSA patency is essential for preventing spinal cord ischemia before extensive aortic coverage.

What procedure was used to restore LSA perfusion after bypass occlusion?

An in situ fenestration on a zone 2 frozen elephant trunk graft was performed using the electrified wire technique, followed by balloon-expandable covered stent implantation.

How was LSA recanalization confirmed after the intervention?

Postoperative imaging confirmed LSA patency.

Sep 28, 2026

Uploaded by Oliver