Endovascular repair of the aortic arch: State of the art

Abstract

Background Open total arch replacement remains the gold standard treatment for aneurysms and dissections involving the aortic arch. However, high‐risk surgical candidates may benefit from endovascular techniques to reduce the risk of perioperative mortality and morbidity, especially neurologic complications. Numerous endografts are available for investigational use in the aortic arch as part of investigational device exemption (IDE) programs. Some devices are fenestrated or scalloped, while others are branched, ranging from single branch to triple branch stent‐grafts. Furthermore, chimney techniques and in situ fenestration may be utilized in bailout or emergent situations. Results Initial results describing outcomes of complete endovascular repair of the aortic arch are encouraging, with current data estimating that technical success ranges from 84.2% to 100%. Moreover, operative mortality may be as high as 13.2%, while neurologic complications also remain common, with stroke rates being as high as 20% and spinal cord ischemia being as high as 3.1%. However, more data are necessary to determine the comparative treatment effect of endovascular stent‐grafting of the aortic arch, compared with conventional open and hybrid repairs. Longitudinal follow‐up is also lacking, which will determine the long‐term durability of endografts in the aortic arch. Nevertheless, endovascular repair represents an important opportunity for improving outcomes in patients with complex and potentially devastating pathologies of the aortic arch.

A canine model of aortic arch aneurysm created with autologous pericardium

“…Endovascular repair has been the most popular treatment for thoracic aortic aneurysms because of the lower incidence of procedure-related mortality and morbidity. 3 , 4 , 5 However, the aortic arch remains a challenge for endovascular repair because the supra-aortic vessels cannot be covered by stent grafts. 4 Total endovascular techniques in the aortic arch include the fenestrated stent graft, branched stent graft, and chimney technique.…”

“… 3 , 4 , 5 However, the aortic arch remains a challenge for endovascular repair because the supra-aortic vessels cannot be covered by stent grafts. 4 Total endovascular techniques in the aortic arch include the fenestrated stent graft, branched stent graft, and chimney technique. 6 , 7 , 8 , 9 , 10 , 11 Fenestrated stent grafts and branched stent grafts are complex and not widely available.…”

“…Compared to open surgery and hybrid surgery, endovascular repair has lower rates of procedure-related mortality and morbidity. 3 , 4 , 5 However, the aortic arch is still a challenge when performing endovascular repair because the supra-aortic vessels cannot be covered by stent grafts. 4 New endovascular devices and techniques should be investigated to overcome this challenge.…”

“… 3 , 4 , 5 However, the aortic arch is still a challenge when performing endovascular repair because the supra-aortic vessels cannot be covered by stent grafts. 4 New endovascular devices and techniques should be investigated to overcome this challenge. To date, there has been no animal model suitable for studying these new endovascular devices and techniques applied to the aortic arch.…”

Commentary: The aberrant right subclavian artery is not so abhorrent: Central arch reconstruction for acute type B dissection

“…The authors observed very favorable aortic remodeling in all 3 patients who underwent complete arch reconstruction, the single patient with ascending replacement alone and hybrid repair did require additional aortic intervention in the form of open thoracoabdominal aneurysm repair 4 years later. 3 The strength of this article is to describe a technique that can lead to definitive management in the setting of ARSA with ATBAD, especially if there is not sufficient landing zone for TEVAR with bilateral carotid-subclavian bypass.…”