Zone 2.5 homemade fenestrated tevar for a saccular aneurysm just distal to the left subclavian artery without additional devices

• A 67-year-old man with a saccular aneurysm just distal to the left subclavian artery was successfully treated using a Zone 2.5 homemade fenestrated TEVAR. • A 1-cm-square fenestration was preoperatively created in the non-stented fabric portion of a Valiant® graft, reinforced with 5-0 Prolene sutures and L-shaped radiopaque markers. • The fenestration was strategically positioned to partially overlap the LSA ostium (“Zone 2.5 placement”), enabling perfusion without additional devices such as Viabahn® or debranching. • Postoperative CT confirmed complete aneurysm exclusion and preserved LSA flow at 6 months, with no endoleak, neurologic complications, or need for reintervention. • This simplified, cost-effective approach may offer a viable alternative for high-risk patients requiring LSA preservation without off-label bridging stents. Thoracic endovascular aortic repair (TEVAR) for saccular aneurysms located just distal to the left subclavian artery (LSA) often necessitates proximal landing in Zone 2. Preserving LSA perfusion in such cases typically requires additional devices such as Viabahn® stents or surgical debranching, which may be invasive, costly, or off-label in Japan. We report the case of a 67-year-old man with multiple comorbidities, including prior abdominal aortic aneurysm repair, who was found to have a 33-mm saccular aneurysm located 7 mm distal to the LSA. To preserve LSA perfusion without using adjunctive devices, we modified a Valiant® thoracic stent graft by creating a 1-cm square fenestration in the non-stented portion of the graft fabric. The fenestration was reinforced with 5-0 Prolene sutures and marked with an L-shaped radiopaque marker using a Micropuncture® sheath. The stent graft was deployed in a “Zone 2.5” position, wherein the fenestration partially overlapped the LSA ostium. Intraoperative angiography confirmed adequate LSA perfusion via the fenestration. No additional stent or bypass procedure was required. The postoperative course was uneventful. Six-month follow-up computed tomography angiography confirmed complete aneurysm exclusion, appropriate graft positioning, and sustained LSA perfusion without endoleak or complications. Homemade fenestrated TEVAR with Zone 2.5 deployment using a self-modified stent graft represents a safe, effective, and economical alternative to conventional techniques requiring adjunctive devices. This strategy may be particularly beneficial for elderly or high-risk patients.