Utilizing a long sheath to minimize atheroma manipulation (minimal manipulation approach) during Zone 1 and 2 thoracic endovascular aortic repair with a shaggy aorta.

We have adopted a simple and reproducible approach, "minimal manipulation approach," since January 2021 in five patients to minimize the risk of thromboembolic events during Zone 1 and 2 thoracic endovascular aortic repair (TEVARs) with shaggy aorta. The approach consists of two parts: ① Use of a 65-cm-long sheath (dry seal) to deliver the endografts without touching the protruding atheroma. Covering the atheroma with the first endograft delivered at Zone 3 to the mid-descending aorta (paving the aorta), and second endograft insertion and deployment through the paved aorta with first endograft. ② Protection of the left subclavian artery using balloon catheter during TEVAR. No in-hospital mortality was recorded, and none of the patients had stroke, spinal cord ischemia, or distal embolic events.