Endovascular Techniques for Aortic Arch Pathologies

Endovascular repair of aortic arch disease has evolved rapidly, offering less invasive alternatives to open surgery. Modern approaches employ thoracic endovascular aortic repair (TEVAR) in conjunction with specialised stent-grafts designed to maintain blood flow to the supra-aortic branches. These include fenestrated and branched devices, chimney and periscope techniques, and physician-modified grafts. Careful selection of proximal landing zones and optimisation of device conformability are essential to prevent endoleak, migration and neurologic complications. Computational fluid dynamics has provided insight into postoperative vascular remodelling, while advanced imaging facilitates precision in device deployment. Collectively, these developments have expanded the applicability of endovascular solutions for aneurysms, dissections and penetrating ulcers of the arch, reducing perioperative morbidity and shortening hospital stay on a global scale.

Research from Nature Portfolio

One multicentre investigation demonstrated that physician-modified fenestration on single-branched stent-grafts can effectively preserve an isolated left vertebral artery during TEVAR under local anaesthesia. All patients achieved technical success, with maintained arterial patency and minimal major complications over a median follow-up of 28 months. This approach highlights the practicality of in-situ graft modification for branch vessel protection in complex arch anatomy.

A comparative study of left subclavian artery revascularisation during TEVAR for type B aortic dissection evaluated carotid-subclavian bypass against chimney graft implantation. Both strategies achieved high technical success, yet chimney grafts offered shorter intensive care stays and zero 30-day stroke, while bypass conferred durable patency. The work underlines the tailored selection of revascularisation techniques based on patient risk profiles.

Endovascular Techniques for Aortic Arch Pathologies publication trend

The graph below shows the total number of articles in endovascular techniques for aortic arch pathologies across all publications each year (not limited to Nature Index journals).

Technical terms

Thoracic endovascular aortic repair (TEVAR): Minimally invasive placement of a stent-graft within the thoracic aorta to exclude pathology.

Fenestrated stent-graft: Endograft with preformed openings to accommodate blood flow into branch vessels from the main lumen.

Chimney graft: Parallel stent placed alongside the primary endograft to preserve perfusion of an aortic branch vessel.

Inner branched stent-graft: Device featuring integrated internal branches to maintain flow to supra-aortic arteries.

Endoleak: Persistent perfusion of the aneurysm sac outside the stent-graft after endovascular repair.

Ishimaru zones: Anatomical segments of the aortic arch defining standardised landing sites for endograft deployment.

References

1. Utilizing physician modified fenestration on the castor branched stent technique for reconstruction of an isolated left vertebral artery on the aortic arch. Scientific Reports (2024).
2. The strategies and outcomes of left subclavian artery revascularization during thoracic endovascular repair for type B aortic dissection. Scientific Reports (2018).
3. Analysis of Postoperative Remodeling Characteristics after Modular Inner Branched Stent-Graft Treatment of Aortic Arch Pathologies Using Computational Fluid Dynamics. Bioengineering (2023).
4. Outcomes of endovascular repair of aortic aneurysms with the GORE thoracic branch endoprosthesis for left subclavian artery preservation. Journal of Vascular Surgery (2022).
5. Early Outcomes of Left Subclavian Artery Revascularization Using Castor Single-Branched Stent-Graft in the Treatment of Type B Aortic Dissection or Intramural Hematoma. Annals of Thoracic and Cardiovascular Surgery (2020).