Thoracic endovascular repair of a ruptured thoracic aortic aneurysm with in situ laser fenestration of the left subclavian and left common carotid artery

Most thoracic aortic aneurysms (TAAs) are asymptomatic and often diagnosed at the time of rupture. TAAs involving the proximal arch require adequate coverage with thoracic endovascular aortic repair, which is timely and challenging in emergent ruptures. In situ laser fenestration is a novel method of arch revascularization. We present an 85-year-old man with zone 2 aortic pathology, a ruptured TAA, and a history of a left internal mammary to left anterior descending artery bypass. This case report demonstrates feasibility of a zone 1 repair for a ruptured TAA involving left carotid and left subclavian fenestration in a patient requiring unique attention to left internal mammary artery patency.