The Leak-Loop Technique for In Situ Fenestrated Thoracic Endovascular Arch Repair in Extensive Aortic Intramural Haematoma With Zone 0 Involvement: A Case Report.

PURPOSE: To report the first application of the Leak-Loop Technique (LLT) that combines controlled endoleak and dual guidewire loop stabilization to address cerebral perfusion maintenance and endograft malpositioning during in situ fenestrated thoracic endovascular arch repair (fTEVAR) under urgent resource-limited setting.

CASE REPORT: A 52-year-old man presented with acute progressive chest pain. Computed tomographic angiography identified an extensive subacute intramural haematoma (IMH) with penetrating atherosclerotic ulcer (PAU). In the absence of open surgical infrastructure and a customized device, in situ fTEVAR using the LLT was performed. Dual U-shaped guidewire loops created via same-sheath snare capture at each carotid access site anchored the proximal endograft and prevented rotational displacement during deployment. A pre-positioned balloon inflated at zone 0 prior to endograft deployment created a controlled gutter between the balloon shaft and aortic wall, maintaining antegrade supra-aortic branch perfusion throughout the fenestration interval. Sequential in situ fenestration and supra-aortic branch reconstruction were completed without complications. At 6-month follow-up, all branch stents were patent and the endograft was stable without endoleak.

CONCLUSIONS

The LLT maintained cerebral perfusion through a self-limited controlled gutter and prevented endograft malpositioning during in situ arch fTEVAR for extensive subacute IMH with PAU. Six-month branch patency supports technical feasibility pending prospective validation.Clinical ImpactThe Leak-Loop Technique provides a reproducible, fully endovascular solution to cerebral perfusion maintenance and endograft malpositioning during in situ fenestrated thoracic endovascular arch repair (fTEVAR) using only commercially available equipment, making it particularly applicable in urgent or resource-limited settings where custom devices and open surgical infrastructure are unavailable. The 6-month outcomes suggest its potential as a viable approach in this challenging clinical scenario pending prospective validation.