Dr. Carla van Rijswijk

Stentgrafts in de aortaboog
Open surgery has represented the gold standard of care for many acute and chronic pathologies of the aortic arch. Acute aortic syndromes such as dissection, aneurysmal disease, intramural hematoma, and penetrating ulcers present a complex and variable challenge to treating physicians. Open surgery frequently requires cardiopulmonary bypass and circulatory arrest, which is associated with an unavoidable physiological burden that places these patients at a significant risk of perioperative morbidity and mortality.

In recent years, with innovations in the endovascular field, endovascular solutions for pathologies of the aortic arch and ascending aorta have become available. At first reserved only for highly selected patients unfit for open surgery, but now endovascular aortic arh repair is being offered to patients with suitable anatomy (without genetic aortic syndromes) in experienced centers after multidisciplinary team discussion (1, 2).

Aortic arch aneurysms typically represent either distal extension of ascending aortic pathology or the proximal extent of thoracic and thoracoabdominal aortic aneurysms (TAAAs). Several options have been used, ranging from hybrid repair with surgical debranching to total endovascular repair with in situ fenestrations and manufactured fenestrated and branched devices. In general, most patients are treated either with a proximal repair in zone 0 or a distal repair in zone 2. Because of the relative proximity of the left carotid artery and innominate artery, use of zone 1 for endovascular repair is rarely possible.

Careful patient selection, device design planning, and use of intraoperative adjuncts and imaging techniques have yielded a high technical success for endovascular total arch repair. A multicenter global feasibility study evaluating three-vessel inner-branch stent grafts for treatment of aneurysms and dissections reported 100% technical success (3).

The presentation will provide an overview on indications, available custom-made branched and fenestrated as well as off-the-shelf devices, some technical aspects, and feasibility studies of endovascular arch repair both in elective and emergent situations as endovascular total arch repair provides a valuable alternative option for patients who are poor surgical candidates, and technical success is high with careful patient selection. Learning from current experiences of the multicenter collaborations, anticipation of complications using pre-emptive strategies such as preparation of target vessel landing zones, and use of a total femoral approach can potentially lower reintervention rates in the future.

References
1. Oderich GS, Tenorio ER, Mendes BC, et al. Midterm outcomes of a prospective, nonrandomized study to evaluate endovascular repair of complex aortic aneurysms using fenestrated-branched endografts. Ann Surg. 2021;274:491-499.
2. Clinical cases referring to diagnosis and management of patients with thoracic aortic pathologies involving the aortic arch: a companion document of the 2018 European association for cardio-thoracic surgery (EACTS) and the European society for Vascular surgery (ESVS) Expert consensus document addressing current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch. Eur J Vasc Endovasc Surg, 57 (2019), pp. 452-4602.
3. Tenorio ER, Oderich GS, Kölbel T, et al. Multicenter global early feasibility study to evaluate total endovascular arch repair using three-vessel inner branch stent-grafts for aneurysms and dissections. J Vasc Surg. 2021;74:1055-1065.

Bio
Carla van Rijswijk (MD PhD) is European Board certified Interventional Radiologist and fellow of CIRSE. Works as an Interventional Radiologist in Leiden University Medical Center (LUMC) performing minimal invasive image-guided oncological interventions and arterial endovascular treatments with special interest in endovascular aortic treatment.