First-generation college-graduate medical students are those whose parents have not earned a postsecondary undergraduate degree (including associates, bachelor's, master's, or doctorate). 1 The mountain is steep and the climb is daunting for first-generation college graduates attending medical school, who will be termed first-generation medical students for this commentary. Up to 20% of medical students are first-generation and half of them are underrepresented minorities (URM). 1,2 These individuals find that the challenges they encountered in college persist as they progress to medical school. These may include racial/ethnic discrimination, lack of work-life balance, difficulties with studying and time management, financial insecurity, feelings of imposter syndrome, and the fear of failure. 1 CHARACTERIZATION OF FIRST-GENERATION AND CONTRIBUTIONS TO HEALTH CAREDespite these challenges, first-generation medical students have noteworthy qualities to offer to the field of cardiothoracic (CT) surgery. The training and lifestyle within this field requires resilience, grit, and the ability to overcome adversity. Having overcome the challenges of entering postsecondary school (eg, acquiring cultural and academic capital and finding support or mentorship), firstgeneration medical students have developed resilience and a growth mindset. Alvarado and colleagues 3 performed a questionnaire among first-generation college students and their counterparts, which included the Brief Resilience Scale to qualitatively measure level of resilience. The study found that first-generation college students were more resilient than their counterparts. 3 Further, a cited study by Schneider and colleagues 4 demonstrated that emotional intelligence directly enhances thinking, problem solving, and creativity in these individuals. These qualities can augment a growth mindset, where talents or skills can be developed by hard work, resilience, accepting feedback, and learning and growing from experiences, subsequently allowing for a more positive affect. 3 These traits are helpful for CT surgeons faced with long hours, difficult and taxing surgical procedures, and the management of patients with complex cardiothoracic conditions. Empathy, cultural competence, and an insight into health and health care disparities are also valuable qualities of first-generation medical students. 1 A first-generation medical student described an experience in an article published by the Association of American Medical Colleges. 5 Addressed are the striking reflections of herself and her family members in patients when they share their stories with her.

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To date, emergent total endovascular aortic arch repair has not been described in the literature. We present a 67-year-old female with a poorly differentiated posterior mediastinal sarcoma. Imaging obtained was concerning for intravascular extension of the tumor into the thoracic aorta. While awaiting radiation therapy, the patient complained of worsening chest and arm pain, vital signs demonstrating tachypnea and hypoxia. Subsequent imaging revealed an increase in vascular erosion, concerning for a contained rupture, with complete obliteration of the left mainstem bronchus. The patient was emergently taken for percutaneous endovascular repair of her aortic arch. A three-vessel physician modified fenestrated graft was created and deployed with concurrent stenting of the innominate, left carotid, and left subclavian arteries. Interval computed tomography angiography revealed patency in all stented vessels, with no endoleak and no evidence of pseudoaneurysm. The patient was able to undergo chemotherapy with favorable decrease in tumor burden. Total endovascular aortic arch repair, when planned carefully, is an attractive option in high-risk patients who are otherwise not ideally suited for open total arch replacement.