LAUSR

Commentary: Extension of the proximal landing zone of TEVARs allows formore patients with proximal descending thoracic aortic aneurysms or dissections to be treated endovascularly. Detailed planning and simplicity is the key to technical success. Although insertion of a scalloped TEVAR to achievemore proximal aortic arch seal zones is by nomeans a simple technical exercise, itmay prove simpler with better long-term results than using chimneys and snorkels, burningholes throughTEVARsto insert a side-branchgraft, orperformingcarotid-carotidbypasses. Theconceptof theproximal scallop is to increase the proximal landing zone in the inner curvature of the archwithout compromising thepatency of supra-aortic branches. Before trying this at home, these cases are challenging and expertise is required, including obtaining detailed angiography (two angiograms at perpendicular angles to aid the positioning of the scallop, perpendicular left anterior oblique projection to align the distal marker of the scallop just distal to the targeted vessel), understanding the nuances of advancing the graft (as the device navigates the anterior portion of the aortic arch, it tends to rotate toward the left anterior side of the aorta and excessive torque should be avoided), and using temporary rapid right ventricular pacing. There are certainly limitations of applying scalloped TEVARs, but the technique may expand our horizons to treat proximal aortic lesions.