Endografting of the Aortic Arch

Abstract

In recent years, endovascular repair with stent-grafts has made great advances as a minimally invasive alternative to conventional open surgery in the treatment of aortic aneurysm and dissection. Although many commercial endograft systems are now used worldwide for the treatment of these pathologies in the abdominal aorta, only a few dedicated stent-grafts have been developed for use in the thoracic aorta. However, these secondgeneration commercial endografts have almost identical specifications and performance profiles in terms of structure, function, and delivery mechanism as stent-graft systems employed in the abdominal aorta. Thus, endografts have been used in the thoracic aorta with little consideration to the morphological and hemodynamic characteristics specific to the aortic arch and the deployment techniques needed to navigate this curved region of the thoracic aorta. This review will survey the literature on aortic arch stent-graft repair and identify key elements critical to the successful design of an endograft to treat lesions in the aortic arch.

Hybrid treatment of isolated aortic arch aneurysms

“…There were several reasons for this long wait. The need to develop an endograft large enough for the ascending aorta -decidedly larger than the abdominal aorta -that would not give rise to problems at the transfemoral access point [14]. An important development was the creation of a small, nontraumatic endograft tip that would not damage the aortic valve during endograft placement.…”

“…Another hindrance to the use of this approach in aortic arch and ascending aortic aneurysms was the increased risk of endograft migration due to high blood pressure, mechanical stress produced by the heart and possible progression of aneurysmal disease. Further problems may arise in relation to the different landing zones on the aorta, the angle between the aortic arch and the descending aorta, which is not well suited to the stiffness of endografts, and the anatomical peculiarity of the [14]. aortic arch, with the supra-aortic vessels arising at short intervals along its convex surface [14].…”

“…Further problems may arise in relation to the different landing zones on the aorta, the angle between the aortic arch and the descending aorta, which is not well suited to the stiffness of endografts, and the anatomical peculiarity of the [14]. aortic arch, with the supra-aortic vessels arising at short intervals along its convex surface [14]. The concavity of the aortic arch and emergence of the supra-aortic vessels from its convex surface make it difficult to seal this portion of the aorta with an endograft.…”

“…The concavity of the aortic arch and emergence of the supra-aortic vessels from its convex surface make it difficult to seal this portion of the aorta with an endograft. These technical difficulties have been partially overcome by second-generation endografts, which are much more flexible than the earlier devices and thus able to adapt better to the curvature of the arch, as well as being equipped with effective fixing and landing systems [14]. In addition, during the planning phase, the use of MSCT angiography with its high spatial and temporal resolution and the possibility of performing electrocardiography-gated examinations can increase the diagnostic accuracy of MSCT by enabling the attenuation or elimination of cardiac motion artefacts, especially at the level of the ascending aorta and supra-aortic vessels, with 3D volume rendering (VR), multiplanar reconstructions (MPR) and 3D virtual endoscopy (VE).…”

Type IIIb Endoleak after Thoracic Endovascular Aortic Repair Caused by Endoanchor Dislocation

“…Centerline measurements revealed a diameter of 38 mm in the arch zones 2 and 3. 5 In the first procedure, the patient underwent carotid-subclavian bypass grafting (8 mm polyester graft, Atrium Medical Corporation, Hudson, NH) to create a landing zone of 15 mm length in zone 2 and to maintain antegrade flow to the spinal cord after intended left subclavian artery coverage. 6 were circumferentially deployed to prevent type Ia endoleak and migration.…”