Endovascular Aortic Arch Repair

Today, open surgery is considered the gold standard in treating the ascending aorta and the aortic arch. However, conventional surgical techniques for managing the aortic arch are invasive and frequently associated with a significant systemic inflammatory response syndrome and related complications. Therefore, patients with multiple comorbidities are often classified as high risk and are denied open repair. Over the past 10 years, thoracic endovascular aneurysm repair (TEVAR) has prevailed as the treatment of choice for pathologies of the descending aorta and aortic arch up to Ishimaru zone 2. The superiority of TEVAR in comparison to open repair in reducing perioperative and long-term severe morbidity has been demonstrated in a prospective comparative study.1 In high-volume centers and in patients at low risk, surgical techniques such as complete open repair of the aortic arch or the hybrid (frozen) elephant trunk have been associated with a mortality rate of up to 9% and a stroke rate of 4% to 12%.2-4 Minimally invasive treatment of aortic arch pathologies faces a number of technical challenges. First, the supraaortic branches perfuse the brain, which has a low ischemic tolerance. Furthermore, the aortic arch is wide, angulated, pulsatile, and is further away from the typical access vessels, the femoral arteries. In addition, the presence of plaque and thrombus in the aortic arch (ie, “shaggy aorta”) increases the risk for brain embolism.5