Staged total arch repair for acute aortic dissection using physician-modified fenestrated thoracic endovascular aortic repair: a case report.

Background: Acute type A aortic dissection is a life-threatening condition requiring prompt surgical intervention. Although extensive repair, such as total arch replacement (TAR) with frozen elephant trunk (FET), may reduce late aortic events, this approach can be technically demanding and may increase procedural invasiveness and patient burden. A staged approach combining initial surgery with subsequent endovascular treatment may represent a practical alternative. Case Description: We report a case of acute type A aortic dissection managed using a staged treatment strategy. Initial surgery was performed using transatrial left-ventricular (TALV) cannulation and partial aortic arch replacement with distal anastomosis in Ishimaru zone 2. This approach was selected to achieve rapid establishment of cardiopulmonary bypass and to avoid more extensive arch reconstruction during the emergency phase. After postoperative stabilisation and follow-up assessment of the residual dissection, physician-modified endograft (PMEG) fenestrated thoracic endovascular aortic repair (TEVAR) was performed as a second-stage procedure. The fenestration was tailored according to postoperative computed tomography (CT) findings, allowing the extension of treatment to the residual dissected arch and descending aorta while using the prosthetic graft as the proximal landing zone. This staged strategy may reduce the invasiveness of the initial lifesaving surgery while preserving the option for more complete aortic treatment after recovery. Conclusions: This case suggests that, in selected patients with acute type A aortic dissection, zone 2 aortic arch replacement followed by staged PMEG fenestrated TEVAR may be a feasible strategy. Careful postoperative assessment of residual dissection is essential to identify patients who may benefit from additional endovascular intervention.