Endovascular total arch replacement techniques and early results

Abstract

During the last 20 years, a clear shift has been observed towards thoracic endovascular aortic repair for different aortic pathologies. However, total endovascular repair of the aortic arch remains technically demanding. Simultaneous perfusion of all supra-aortic arteries without longer cerebral ischemia time, whilst trying to avoid cerebral embolization, labels endovascular aortic arch repair with highest level of technical difficulty and surgical expertise. The aim of this article is to present an overview of the current technical options for endovascular aortic arch repair and their early results. Currently, early results are reported from four endovascular arch replacement techniques: hybrid repair, total endovascular approach, chimney grafts and in-situ fenestration. The early results of these different arch replacement techniques are promising, especially the total arch replacement with custom-made fenestrated or branched stent-grafts. Long-term results are unknown, and larger series results and comparative studies are needed to determine safety and efficacy.

A Case of Type I Debranching Complicated by Anastomotic Pseudoaneurysm: Do Not Ask Too Much of the Ascending Aorta

“…Moreover, the device for total endovascular aortic arch repair is now available. 4 However, the use of zone 0 for a proximal landing zone remains a concern 5 because of the high risk of retrograde Type A dissection and anastomotic pseudoaneurysm potentially related to a compliance mismatch between the stent graft and the ascending aorta. 6 Moreover, the morphological changes in the thoracic aorta induced by the cardiac cycle are quite different in the ascending aorta compared with the descending thoracic aorta.…”

Anatomical Analysis and Feasibility Study of Next-Generation Fenestrated or Branched Stent-Grafts for the Treatment of Arch Aneurysms

“…Only patients unfit for TAR are candidates for TEVAR. 3 Revascularization of the supra-aortic branches is inevitable during TEVAR of arch aneurysms, 4 and numerous techniques, such as surgical debranching, 5 the chimney technique, 6 and in situ fenestration, 7 have produced satisfactory results in selected patient populations. However, all of these methods are associated with a certain level of mortality and morbidity.…”

“…However, all of these methods are associated with a certain level of mortality and morbidity. 3,8 Recently, early clinical experiences with next-generation fenestrated or branched stent-grafts (f/bSGs) have also been reported. 3,[9][10][11][12] These complex procedures obviously mandate precise and detailed anatomical analysis of the arch aneurysm.…”

“…3,8 Recently, early clinical experiences with next-generation fenestrated or branched stent-grafts (f/bSGs) have also been reported. 3,[9][10][11][12] These complex procedures obviously mandate precise and detailed anatomical analysis of the arch aneurysm. Interestingly, even though anatomical analysis of the aortic arch has been previously reported for various aortic pathologies, [13][14][15][16][17][18] a detailed and thorough analysis focusing on arch aneurysms is currently lacking.…”

Fenestrated total arch thoracic endovascular aortic repair: coming of age

“…But total arch TEVAR faces several challenges, the principal ones being preservation of flow into all the aortic arch branches despite covering their ostia with the arch endograft and avoiding intra-procedural cerebral embolization. Several other problems may be encountered during arch TEVAR, which may be anatomic (tortuous arch, type-3 arch, Gothic arch), hemodynamic (due to the force of left ventricular ejection), device-related (inability to conform to arch anatomy and material fatigue) and access-related (lack of suitable large-bore femoral access, iliac disease and aortic tortuosity) [3]. One or more of these factors may conspire to cause device delivery failure, malposition, malapposition and ultimately treatment failure.…”