^ COMMENTARY ——————————————————————————————— ^ Midterm Results of Thoracic Endovascular Aortic Repair With Periscope Graft Revascularization of the Left Subclavian Artery Felix J.V. Schl ¨ osser, MD, PhD 1 ; Wouter Hogendoorn, MD 1 ; and Bart E. Muhs, MD, PhD 1,2 Departments of 1 Surgery and 2 Radiology, Yale University School of Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA. Lachat et al. 1 reported in this issue of the JEVT their midterm results after thoracic endovas- cular aortic repair (TEVAR) with periscope stent-graft revascularization of the left subcla- vian artery (LSA). The article, which describes 14 patients with a mean follow-up of 26 months, provides original, significant, and novel information regarding the specific use of the periscope stent-grafting technique for LSA revascularization. Until now, this specific procedure had been reported only in case reports. TEVAR has rapidly developed during the last two decades, with good results compared with open surgical repair in the management of non-ruptured descending thoracic aortic aneurysms, 2,3 ruptured descending thoracic aortic aneurysms, 4 traumatic thoracic aortic injury, 5 Stanford type B aortic dissection, and other aortic pathology. 6 Because not all patients meet the strict criteria for standard endografts, alternative techniques have been developed, such as custom-made fenestrated and branched endografts. Unfortunately, their clinical role has remained limited due to the increased cost and time required for produc- tion and transport, which could limit their use, especially in emergent situations. Alternative techniques that have become more popular over recent years are collec- tively called ‘‘ CHIMPS’’ (chimneys, peri- scopes, and sandwich grafts) and involve placement of one or more adjunctive stents in aortic side branches and in parallel to the main aortic stent-graft. 7 A chimney stent-graft extends above the proximal landing zone of the aortic stent-graft and so has antegrade inflow from the aorta. A periscope stent-graft extends in the caudal direction, with retro- grade flow coming from the aorta distal to the main stent-graft. A sandwich stent-graft in- volves deployment in-between two main body aortic stent-grafts. Several recent publi- cations have evaluated results of the chimney and periscope techniques, with most reports focusing on the abdominal aorta, and some others describing use in the thoracic aorta. ABDOMINAL AORTA Donas et al. 8 recently reported midterm results of 40 patients who underwent chimney and periscope stent-grafting of pararenal abdominal aortic pathology. Their results showed a low perioperative mortality and favorable treatment success, with significant aneurysm sac shrinkage in .90% of patients during follow-up. Chimney graft patency rates of 98% were reported. Moulakakis et al. 9 performed a meta-analysis of 134 chimney grafts for visceral aortic revascularization and also reported a 98% patency rate and addi- Invited commentaries published in the Journal of Endovascular Therapy reflect the opinions of the author(s) and do not necessarily represent the views of the Journal or the INTERNATIONAL SOCIETY OF ENDOVASCULAR SPECIALISTS. The authors declare no association with any individual, company, or organization having a vested interest in the subject matter/products mentioned in this article. Corresponding author: Felix J.V. Schl ¨ osser, MD, PhD, Section of Vascular Surgery, Yale University School of Medicine, 333 Cedar St. BB 204, New Haven, CT 06520 USA. E-mail: Felix.schlosser@yale.edu J ENDOVASC THER 2013;20:735–737 735 Q 2013 by the INTERNATIONAL SOCIETY OF ENDOVASCULAR SPECIALISTS Available at www.jevt.org