Purpose: This report describes the use of a physician-modified endovascular graft (PMEG) with a preloaded fenestration for the left subclavian artery (LSA) and diameter-reducing ties to facilitate alignment between the fenestration and LSA.Technique: Thoracic endovascular aortic repair (TEVAR) was performed to treat an intramural aortic hematoma originating at the level of the LSA. A Relay Plus endograft was modified with a fenestration for the LSA. Diameter-reducing ties were added, and the fenestration was preloaded. The preloaded guidewire was introduced at the femoral access and externalized at the brachial artery. The PMEG was then introduced via the common femoral artery with the through-and-through guidewire assisting in the orientation of the endograft. Before releasing the diameter-reducing ties, a 12 mm balloon was inflated within the fenestration and LSA. The diameter-reducing ties were released while the balloon was inflated, ensuring precise alignment of the fenestration with the LSA. The LSA was stented using a balloon-expandable covered stent. Completion angiography and computerized tomography angiography at follow-up demonstrated technical success.Conclusion: Constructing a PMEG with diameter-reducing ties and a preloaded LSA fenestration to establish a through-and-through wire could facilitate precise alignment, improving procedural consistency over time of fenestrated TEVAR in zone 2.Clinical Impact Endovascular methods for left subclavian artery (LSA) preservation during thoracic endovascular aortic repair (TEVAR) in zone 2 are gaining in popularity. One promising endovascular treatment option is construction of a fenestrated physician-modified endovascular graft (PMEG). Achieving precise alignment between the fenestration and LSA can be challenging. The current report demonstrates a technique to preload the LSA fenestration to establish a through-and-through wire, which, in combination with diameter reducing ties, can potentially aid in achieving consistent results by obtaining a perfect alignment in a quick manner.