Rescue Chimney Stenting via Direct Carotid Access for Inadvertent Left Common Carotid Artery Coverage During Zone 2 Thoracic Endovascular Aortic Repair

A 66-year-old man with hypertension and a 12-year history of chronic type B aortic dissection underwent thoracic endovascular aortic repair (TEVAR) due to aortic enlargement (60 mm) on computed tomography (CT).The entry tear was located just distal to the left subclavian artery (LSA) (Figure 1, Supplementary Figure 1).A single-branched stent-graft (Castor 38-32×170 mm; branch 14×25 mm, Microport Endovastec, Shanghai, China) was deployed in zone 2 via right femoral access, with left brachial access used for branch catheterization (Figure 2A and B, Supplementary Video 1).Subsequently, a distal stent-graft (Valiant Captivia 34-30×150 mm, Medtronic, Minneapolis, MN, USA) was overlapped.An LSA endoleak was resolved by extending the branch (SEAL 12×60 mm, S&G Biotech, Yongin, Korea).However, opacification of the left common carotid artery (LCC) was lost likely due to coverage of the LCC from proximal stent-graft migration during deployment (Figures 2C and 3A).Emergency access to the LCC was obtained under ultrasound guidance to avoid puncturing calcified plaques (Figure 3B and D).A self-expanding stent (Epic 10×40 mm, Boston Scientific, Marlborough, MA, USA) was deployed retrogradely using the chimney technique (Supplementary Video 2).Final aortography demonstrated restored flow in the LCC and patent LSA without endoleak (Figure 3C).Hemostasis was achieved using a closure device (Perclose Proglide, Abbott, Abbott Park, IL, USA).The patient remained free of neurological symptoms after the procedure.Follow-up CT confirmed exclusion of the false lumen and patency of all branches (Figure 4, Supplementary Figure 2).This case highlights retrograde carotid stenting as an effective rescue strategy for accidental LCC coverage during zone 2 TEVAR.1-5)