One of the principal reasons for failure of endovascular aneurysm repair (EVAR) is the occurrence of endoleaks, which regardless of size or type can transmit systemic pressure to the aneurysm sac. There is little debate that type I endoleaks (poor proximal or distal sealing) are associated with continued risk of aneurysm rupture and require treatment. Similarly, with type III endoleak, there is agreement that the defect in the device needs to be addressed; however, what to do with type II endoleaks and their effect on long-term outcome are not so clear. Aneurysm sac change is a primary parameter for determining the presence of an endoleak and assessing its impact. While diameter measurement has been the most commonly used method for determining sac changes, volume measurement has now been proven superior for monitoring structural changes in the 3-dimensional sac. Determining the source of an endoleak and the direction of flow are necessary for proper classification; however, while computed tomographic angiography has high sensitivity and specificity for detecting endoleaks, it is limited in its ability to show the direction of flow. Contrast-enhanced duplex ultrasound, on the other hand, is better able to quantify flow and characterize endoleaks. Flow is evidence of pressure, and increasing intrasac pressure increases wall tension, thus inducing progressive aneurysm expansion until rupture. Hence, determining intrasac pressure is becoming a vital component of endoleak assessment. All endoleaks can create systemic pressure inside the aneurysm sac, and there are a variety of intrasac pressure transducers being evaluated to assess this effect. A clinical pathway for patients with suspected type II endoleaks is based on a combination of imaging and pressure measurements. Imaging alone requires at least two interval examinations to determine the trend, while pressure measurements give immediate reassurance or an indication to intervene. Although still under development, pressure measurement is destined for general use and will provide a scientific basis for the management of type II endoleaks.

Of all of the aortic segments, the aortic arch is the last frontier for endovascular treatment. The main difficulty for arch repair is the lack of an appropriate proximal landing zone of at least 2 to 3 cm required for endograft sealing and anchoring to diminish the risk of endoleaks or migration. We used branched endografts to treat two cases of aortic aneurysms that required complete arch endografting, with successful aneurysm exclusion.

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Aortic arch aneurysms involving the major vessels of the neck pose great challenges in their repair. Open repair of these aneurysms are associated with a significant morbidity and mortality. The major challenge for endovascular repair of these complex aneurysms is the maintenance of cerebral perfusion during stent implantation and long‐term durability. This paper discusses preoperative planning and technical aspects to successful endovascular repair of a large aortic arch aneurysm involving the distal take‐off of the left subclavian artery.

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