Physician-modified endografts for left subclavian artery revascularization during aortic arch and descending thoracic endovascular repair: a literature review and center experience

Background: Management of the left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR) in zone 2 remains debated, as intentional coverage without revascularization increases the risk of cerebrovascular accident and spinal cord ischemia. Among available strategies, physician-modified endografts (PMEGs) have emerged as a practical, fully endovascular option for LSA preservation. Methods: The study reports the single-center experience at San Raffaele University Hospital, Milan, with PMEGs for TEVAR involving the distal aortic arch and the proximal descending thoracic aorta. In addition, a review of the current literature on PMEG-based LSA revascularization was conducted, including studies published between 2016 and 2024 addressing technical success, neurologic events, and mid-term patency. Results: Fourteen consecutive patients operated between February 2023 and October 2024, all in urgent or emergent settings, were included in this study. PMEG implantation achieved 93% technical success with no 30-day mortality, stroke, or spinal cord ischemia. At a mean follow-up of 18.4 months, LSA patency was 92.3%, with a single reintervention for branch occlusion. Consistently, literature data demonstrate >90-95% technical success, stroke rates of 0-5%, and durable (>95%) LSA patency up to 3 years. Conclusions: Initial experience with PMEG-based LSA revascularization seems to offer a valuable, fully endovascular alternative for Zone-2 TEVAR in urgent or emergent cases that can’t wait for standard custom-made device manufacturing. Meticulous imaging-guided planning and standardized modification protocols are essential for durable outcomes. While long-term data remain limited, accumulating evidence supports PMEGs as an effective bridge between conventional hybrid approaches and dedicated branched endografts.