Technical considerations of a physician-modified dual-fenestrated Gore thoracic branch endoprosthesis for total endovascular aortic arch repair.

Total endovascular aortic arch repair is a less invasive option to both open and hybrid surgery for complex arch disease. Currently, the only U.S. Food and Drug Administration-approved branched endovascular device for aortic arch repair in the United States incorporates a single-branch design, often necessitating adjunctive cervical debranching to achieve complete arch reconstruction. Although multivessel fenestrated and branched arch technologies are available in selected regions outside the United States, many remain investigational or are not broadly accessible because of regulatory or commercial limitations. In this context, we have selectively applied physician-modified endograft techniques in patients who are considered poor candidates for open total arch replacement or in whom cervical debranching required for zone 0 single-branch repair is associated with an unacceptably high operative risk or is anatomically unfavorable. Physician-modified endografts can be a valuable alternative in patients who are at high risk for open arch or complex cervical debranching. In this report, we detail the modification of a GORE Thoracic Branch Endoprosthesis (W. L. Gore & Associates) with dual fenestrations, designed specifically for total endovascular repair of the aortic arch. Device modifications, procedural details, and bailout techniques are described.