Comments regarding 'total endovascular debranching of the aortic arch'.

Endovascular Aneurysm Repair (EVAR) was successfully reported by Dr. Juan Parodi in the early 1990’s. His initial report of this monumental change in the management of aneurysm disease has allowed for the continued evolution of endovascular therapyfor theaorta.Dr. Yoshidaandcolleagues report two difficult cases that demonstrate this continued evolution in endovascular therapies for aneurysmal disease. EVAR and TEVAR have been limited in successfully treating the aortic arch and visceral segment of the aorta due to the natural branching of the aorta. In light of the limits of current technology, surgical debranching procedures have been utilized to expand our ability to treat complex aneurysmal disease of the aortic arch and abdominal aorta. But, these procedures are fraught with a high morbidity and mortality rate. Several reports have highlighted the value of endovascular debranching of the aorta to minimize the morbidity of surgical debranching. Yoshida et al. report a novel technique that treats complex aneurysmal disease of the aortic arch. They present two cases in high-risk patients that were managed in a total endovascular fashion. They utilized a hybrid approach with exposure of the femoral, common carotid, and axillary arteries. They placed 12 Fr sheaths into the common carotid arteries and axillary arteries. In addition to placing a thoracic endograft, they placed a combination Viabahn stents (WL Gore and Associates, Flagstaff, AZ) that varied from 10 to 15 cm in length and were placed as proximally as the sinotubular junction with care taken to avoid coverage of the coronary arteries. The first patient was treatedwith branches into the innominate artery and the left