Endovascular Aortic Arch Repair Research Articles

Avoiding Aortic Valve Passage in Branched Arch Repair by Use of the Modified Balloon Nose Cone Technique.

To demonstrate the Modified Balloon Nose Cone Technique to avoid passage of the aortic valve in endovascular branched arch repair. The technique is demonstrated in a 54-year-old patient after previous open repair of the ascending aorta and mechanical aortic valve replacement due to type A aortic dissection. The delivery system of a custom-made stent-graft with 3 inner branches was modified by subtotally sawing off its nose cone. Using a right transaxillary access, a sheath was introduced over a through-and-through (TAT) wire exiting the left groin and meeting the branched stent-graft in a rendezvous fashion. A balloon was used to bridge the gap between both sheaths. Passing the innominate artery, both sheaths were pushed into the ascending aorta to establish a loop configuration of the balloon until the correct landing zone was reached. The main body was deployed, and the supra-aortic target vessels were connected. After the procedure, the mechanical aortic valve showed unimpaired function. The Modified Balloon Nose Cone Technique broadens the technical armamentarium in endovascular aortic arch repair offering a feasible solution to overcome the need of aortic valve passage. Especially patients with mechanical aortic valve could benefit from this method. To describe the feasibility and safety of the Modified Balloon Nose Cone Technique in a severely comorbid patient with residual Type A aortic dissection and history of ascending aortic repair and mechanical replacement of the aortic valve to broaden the technical armamentarium in endovascular aortic arch repair offering a feasible solution to overcome the need of aortic valve passage.

Percutaneous Carotid Access in Endovascular Aortic Arch Repair: Initial Experience.

Direct percutaneous access to the carotid artery (diPerCa) during endovascular aortic arch repair (EVAAR) can potentially present a minimally invasive access with lesser local adverse events. A retrospective review of consecutive EVAAR between January 2018 and January 2024, in a tertiary referral center, was performed to identify cases, in which diPerCa was used. Patients who were planned for EVAAR with no previous carotid intervention were included. A standardized technique was employed where an ultrasound-guided retrograde puncture of the carotid artery was performed with a micro-puncture set and a suture-mediated closure device (pre-closure technique). Of the 13 included patients, technical success was achieved in 12 (92.3%), with one intraoperative death unrelated to diPerCa. Major complications included one case of carotid pseudoaneurysm and one case of non-flow-limiting carotid dissection. Minor complications were unilateral recurrent laryngeal nerve palsy in one case and new-onset dizziness in one case. All carotid arteries remained patent without stenosis, with one case of non-progressing dissection noted at the conclusion of the mean follow-up of 22.5±2.4 months. Direct percutaneous carotid access with suture-mediated closure devices during EVAAR is feasible with acceptable results and low incidence of clinically relevant neurological and local complications. Further studies are needed to confirm these findings and evaluate long-term outcomes. Direct percutaneous carotid access (diPerCa) during endovascular aortic arch repair (EVAAR) offers a minimally invasive alternative to retrograde access via open surgical exposure. This technique, supported by suture-based closure devices, demonstrates no stroke and low rates of local complications. Overall outcomes are promising, suggesting diPerCa as a feasible option for select patients. Further research is warranted to validate these findings and assess long-term outcomes.

The Use of Short Dilator Tip in Endovascular Branched Arch Repair: A Case Series.

The aim of the study was to investigate the safety and feasibility of branched endovascular arch repair (b-TEVAR) with a custom-made double or triple inner branched arch endograft using a short dilator tip (35 mm) in patients with aortic arch pathologies. Retrospective analysis of all consecutive patients undergoing b-TEVAR with a short dilator tip for the treatment of aortic arch pathologies in a high-volume tertiary center between January 2019 and July 2023. The combined primary endpoint was technical success and perioperative complications caused by the endograft, including tip-induced cardiac injury and trackability issues. Secondary endpoints were major adverse events (MAE), including morbidity, mortality, and reinterventions within 30 days. During a 4-year period, 22 patients (median age 72 years, 16 males) were treated with a custom-made double or triple inner-branched TEVAR for different aortic arch pathologies using a short dilator tip (35 mm). After initial exclusive treatment of patients with previous valve replacement, the use of a short dilator tip became standard. Eighteen patients received a triple- and 4 patients received a double-branched endograft. Seventeen patients (77.3%) underwent elective treatment, while 5 patients underwent urgent repair due to contained rupture or symptomatic aneurysms. The technical success was 100%. No tip-induced cardiac mortality and morbidity occurred perioperatively. The trackability of the device was in no case affected by the short tip. Within 30 days, the MAE rate was 45%, including one death. No re-intervention had to be performed. Endovascular aortic arch repair with inner-branched arch endografts using a short dilator tip (35 mm) appears to be safe and technically feasible and could potentially reduce the risk of fatal myocardial injuries. Due to safe and stable maneuverability and deployment of endograft in zone 0 the use of short dilator tip might have the potential to become standard in endovascular branched arch repair. This is one of the first reports on the use of short dilator tip and associated complications in endovascular branched arch repair.

New Territory Unlocked: Crossing the Mechanical Aortic Valve During Endovascular Aortic Arch Repair

New Territory Unlocked: Crossing the Mechanical Aortic Valve During Endovascular Aortic Arch Repair

Feasibility of endovascular aortic arch repair after hemiarch replacement for acute type A aortic dissection

ObjectiveWe assessed the treatment feasibility of 4 investigational arch endografts currently available in the United States, for patients who have undergone hemiarch replacement for an acute DeBakey I dissection. MethodsWe evaluated 71 consecutive patients for suitability for treatment with the Cook Medical Zenith Arch Branched Device, Gore TAG Thoracic Branch Endoprosthesis, Terumo Bolton Relay Dual Branch Device, and Endospan Nexus Aortic Arch Stent Graft System. Proximal landing zone anatomy was evaluated on postoperative computed tomography angiography using 3-dimensional imaging software and compared against each manufacturer recommended sizing criteria. ResultsTwenty-one patients (29.6%) were deemed unsuitable for branched endograft due to mechanical aortic valve, connective tissue disorder, and extension of dissection into the brachiocephalic trunk (BCT). Forty-one percent were excluded from all devices; 8.5% were candidates for only 1 device, 24% for 2, 4% for 3, and 23% for all 4 devices. Reasons for exclusion included ascending aortic/neck diameter being too large/small, insufficient ascending aorta length, insufficient BCT length, and BCT size being too large. Both patient-related factors (BCT diameter/length, dissection into BCT, and connective tissue disorder) and technical factors (mechanical aortic valve, ascending aorta graft length/diameter) influenced candidacy. ConclusionsDespite the availability of multiple branched endovascular devices, a significant number of patients may be unsuitable for subsequent endoarch repair. Awareness of anatomic inclusion criteria for arch endografts and modification of surgical technique for creation of a suitable landing zone at the initial operation may increase the likelihood of successful endovascular repair in the future.

Outcomes after Endovascular Arch Repair in Patients with a Mechanical Aortic Valve: Results from a Multicentre Study

The aim of this study was to investigate outcomes after endovascular aortic arch repair in patients with a mechanical aortic valve where the valve needs to be crossed. An international, multicentre, retrospective observational study was undertaken including all consecutive patients who underwent endovascular arch repair with mechanical aortic valve crossing. From March 2020 to August 2023, 12 patients were included in the study (median age 55 years, interquartile range 45, 67 years; 58% male). Five patients (42%) had a genetically confirmed connective tissue disorder (CTD) and three more had a high clinical suspicion of CTD. Most patients had a bileaflet valve (11/12; 92%) and one patient had a monoleaflet one. All patients had previously undergone surgical ascending aortic repair. Technical success was 100% with successful completion of the procedure with no valve damage. Two deaths (17%) were observed in the first 30 days post-operatively with no signs of valve malfunction: one patient died of major stroke due to excessive wire and sheath manipulation in the arch; and another due to cardiac arrest of unknown cause, with no valve damage being detected in the autopsy. No intra-operative technical difficulties regarding valve cannulation were observed. During a median follow up of eight months, one patient died fifteen months after the procedure owing to non-aortic related causes, and four endoleaks were present on the latest computed tomography angiography, none type I or III. Endovascular aortic arch repair in a selected group of patients with a mechanical aortic valve treated in experienced, high volume aortic centres seems technically feasible and reasonably safe. These preliminary results underline the complexity of the procedure and should be validated by larger cohort studies. With careful patient selection and adequate physician experience, the presence of a mechanical aortic valve could potentially no longer pose a major contraindication for endovascular arch repair in the future.

Total endovascular arch repair: Initial experience in Bologna

ObjectivesIn the last few years, fenestrated, branched, or scalloped custom grafts have become available for aortic arch repair. Open surgery is the gold standard, but arch thoracic endovascular aortic repair (TEVAR) is indicated for high-risk patients. We focused on total endovascular aortic arch replacement with a zone 0 or zone 1 landing zone to describe its short- and long-term outcomes. MethodsWe retrospectively analyzed patients who underwent arch TEVAR with a zone 0 or zone 1 landing zone at our center. We then performed a Kaplan-Meier analysis for survival and freedom from reintervention at follow-up. ResultsFrom May 2017 to November 2023, 15 patients underwent elective arch TEVAR, having been deemed unfit for open surgery. Mean age was 74.7 ± 7.8 years. The most frequent procedure was fenestrated endovascular aortic repair with a left carotid-subclavian bypass (LCSB) (6; 40%), followed by double-branched graft with LCSB (5; 33.3%) and triple-branched graft (2; 13.3%) and scalloped graft with LCSB (2; 13.3%). There was 1 in-hospital death (6.7%). Perioperative stroke occurred in 2 cases (13.3%). Mean follow-up (FU) time was 16.4 ± 15.1 months. There were 3 deaths at FU, all for noncardiovascular causes, and 1 stroke at FU. One patient required further stenting of the brachiocephalic trunk for a type III endoleak. Survival at 12 months was 87.5% and freedom from reintervention was 85.7%. ConclusionsTotal endovascular aortic arch repair with custom-made prosthesis is a safe and effective procedure in patients with prohibitive surgical risk. Stroke remains the main complication with significant rates.

A Scoping Review of Definitions of Success in Endovascular Aortic Arch Repair.

The present standard of care to treat aortic arch pathologies is open surgical repair with cardiopulmonary bypass and deep hypothermic arrest. With approaches for total endovascular and extra-anatomic cervical debranching hybrid arch repair becoming more diverse, understanding what is considered a successful operation is prerequisite for a rigorous comparison of techniques. This review describes the specific outcomes reported, the rates of success, and the definitions of technical and clinical success in total endovascular and extra-anatomic cervical debranching hybrid aortic arch repair. A comprehensive search of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials was performed. Studies with patients undergoing total endovascular or hybrid extra-anatomic cervical debranching repair of the aortic arch were included. Any publications including only patients with Ishimaru zone 2 or distal repairs were excluded from this review. Studies with less than 5 patients were excluded. Data extraction was performed by one author. Data items included were study design, procedure type, procedural details, underlying pathology, type of cervical debranching, type of endograft repair, surgical outcomes, definition of cerebrovascular events, technical success, and the definition of technical success. Of 1754 studies screened for review, 85 studies with 5521 patients were included. By frequency, the included studies examined the following interventions: fenestrated devices, branched devices, parallel grafting. Most studies were retrospective single-institution studies. There were no randomized controlled trials. Short-term mortality and cerebrovascular events were nearly universally reported, present in 99% and 95% of studies reviewed, respectively. Only 27% of studies provided an explicit definition for cerebrovascular events. While 75% of studies reported a technical success rate, only 45% of those studies provided explicit criteria. Clinical success rates were infrequently reported, present in only 5.9% of studies reviewed. The definitions of technical success that were provided fell short of analogous defined reporting standards in nearly all studies, inflating technical success rates. Definitions of cerebrovascular events and technical success require stringent criteria to uniformly compare various methods of endovascular aortic arch repair. A societal consensus document for reporting standards of endovascular aortic arch repair would allow for higher-quality outcomes research. Total endovascular and extra-anatomic cervical debranching hybrid operations are being increasingly utilized for complex aortic arch repair. These techniques, however, can be associated with serious complications. Currently, there is no accepted metric to define technical or report clinical outcomes. Due to the paucity of high-quality data, use of these approaches may be limited in clinical practice. This study emphasizes the need for the development of standards for reporting outcomes in endovascular aortic arch repair. Future studies can then utilize these benchmarks, whcih will allow for improved efficacy and safety in these techniques.

Technical Aspects of Exclusive Transfemoral Route for Total Endovascular Arch Repair: A Custom-Made Device With Only Upward-Facing Inner Branches for Aortic Arch Treatment.

The purpose was to demonstrate a new arch endograft configuration to allow total endovascular aortic arch repair exclusive from transfemoral approach. The custom-made multi-branched arch endograft (Cook Medical, Bloomington, Indiana) features 3 inner branches (IBs) for supra-aortic vessels incorporation and complete endovascular arch repair. Traditionally, the innominate and left carotid branches are anterograde IBs, requiring upper access for incorporation of these vessels, and the left subclavian branch is an upward-facing IB that can be incorporated from transfemoral access. We report a novel device configuration with only upward-facing IBs, allowing exclusive transfemoral route for total endovascular arch repair. Technical aspects, implantation technique, and limitations are described thoroughly. Herein is described an arch endograft configuration that simplifies endovascular aortic arch repair, allowing supra-aortic vessel incorporation through a transfemoral route only. This innovative design may serve as another alternative in selected patients. This innovative endograft design, with only upward-facing inner branches, simplifies the total endovascular aortic arch repair by allowing for a exclusively transfemoral approach. This may reduce procedural complexity and minimizes risks associated with multiple access points. It provides another alternative, particularly beneficial for selected high-risk patients for open repair, potentially expanding the applicability of endovascular treatments for aortic arch pathologies.

Anesthetic management integrated in "Aorta Team" approach for Total endovascular aortic arch repair: A case series.

Total endovascular aortic arch repair is nowadays a promising alternative for selected patients with aortic arch disease. These endovascular procedures are technically challenging and require a diligent planning among all members of a multidisciplinary "Aorta Team" integrating cardiovascular anesthesiologists. In fact, endovascular aortic arch repair is a major challenge for anesthesiologists because of the risk of hemodynamic instability, cerebral events and acute kidney injury. In order to achieve the success, it is fundamental to discuss each patient in an individual basis, including perioperative management and care, and to be aware of surgical steps and their potential complications. Considering our previous experience with endovascular thoracoabdominal aortic surgery, we herein summarize our experience with anesthetic management of patients who underwent total endovascular aortic arch repair and its principal outcomes.

360 Driving Technology for Endovascular Aortic Arch Repair: An International Analysis of Relay Branched Outcomes

Abstract Aim The introduction of endovascular aortic arch repair (EAR) represents a paradigm shift in the management of complex arch pathologies. In this multicentre study, a comparative analysis of international outcomes data on the single-, double- and triple-branch RELAY™ endografts is presented. Method Multicentre data was collected prospectively (2019-2022) and stored in an international registry. This was later retrieved and analysed retrospectively. All patients were followed-up for 24 months. Outcomes measured included target vessel patency (TVP), reintervention, stroke, and mortality. Results Of the total 148 patients, 17 (11.5%) received the single-branch RELAY™, 108 (73%) double-branch, and 23 (15.5%) triple-branch. The group characteristics were similar at baseline. Target vessel cannulation and technical success were achieved in 99.3% of patients. TVP at 30 days post-EAR was 100% in all groups, however, this became 93.8%, 74.0% and 100% at 24 months in the single-, double- and triple-branch endograft groups, respectively. As for reinterventions, these were only required with the double-branch RELAY™ (n=50, 34%). Similarly, disabling strokes were only observed in the double-branch group (n=35, 32.4%), and the overall study incidence was 23.8%. Non-disabling strokes had an overall incidence of 12.8% (n=19). The overall mortality rate was 2.7%, with all 4 deaths recorded occurring in the double-branch group. Logistic regression analysis showed a significant association between urgency (acute) and reintervention. Conclusions Our results clearly demonstrate that EAR using RELAY™ Branched is a highly efficacious strategy. Nevertheless, it seems that clinical outcomes with the single- and triple-branch RELAY™ are more favourable than with the double-branch configuration.

852 Total Endovascular Aortic Arch Repair: Is It for Everyone and Where Is Its Evidence?

852 Total Endovascular Aortic Arch Repair: Is It for Everyone and Where Is Its Evidence?

How I Do It: Endovascular Aortic Arch Repair of a Type 1A Endoleak of a Residual Type A Dissection Using the Nexus Device

How I Do It: Endovascular Aortic Arch Repair of a Type 1A Endoleak of a Residual Type A Dissection Using the Nexus Device

Clinical Outcomes Following Total Endovascular Aortic Arch Repair: A Systematic Review and Meta-analysis

Clinical Outcomes Following Total Endovascular Aortic Arch Repair: A Systematic Review and Meta-analysis

Endovascular Arch Repair of Anastomotic Aneurysm and Pseudoaneurysm in Patients after Open Repair of the Ascending Aorta and Aortic Arch: A Case Series

Abstract Background Endovascular techniques have provided new options in the treatment of arch pathologies. Multiple studies have reported good results after endovascular treatment of aortic arch aneurysms and it has developed to be a considerable approach, especially in patients who are unfit for open surgery. In treatment of progressing distal pathologies after open ascending aorta and/or aortic arch replacement, the endovascular arch repair has shown promising results. Aims Aim of study was to investigate the outcomes of endovascular arch repair (b-TEVAR) with a custom-made double or triple branched arch endograft in patients with distal anastomotic aneurysms after open repair of the ascending aorta or proximal arch replacement. Methods Retrospective analysis was conducted of all consecutive patients with anastomotic aneurysms after open surgical repair involving the ascending aorta and/or aortic arch treated with b-TEVAR. All patients were treated with a custom-made double or triple inner-branched arch endograft. Study endpoints were technical success, 30-day and follow up mortality/ morbidity and re-interventions. Results Between 2018 and 2022, ten patients were treated with custom-made double or triple branched TEVAR due to anastomotic aneurysms after open ascending aorta and/or proximal aortic arch replacement. Eight patients received a triple and two a double arch branched endograft. Eight cases were performed electively and two urgently for contained rupture. Technical success was achieved in nine cases (90%). All elective patients survived. Two patients treated due to contained ruptures expired. Within 30 postoperative days, one transient ischemic attack occurred. No early endograft-related re-interventions were necessary. Median follow-up was 20 months. One patient died two months after discharge due to sepsis caused by pneumonia. No further deaths or endograft-related re-interventions were observed. Conclusion Endovascular aortic arch repair with double or triple inner-branched arch endograft for anastomotic aneurysms after open ascending and/or proximal arch replacement is technically feasible and a promising alternative in a patient cohort unfit for surgery.

Sex Comparative Analysis of Branched and Fenestrated Endovascular Aortic Arch Repair Outcomes

Female sex is a risk factor for adverse events after endovascular aortic repair. Sex comparative early and midterm outcomes of fenestrated and branched endovascular aortic arch repair (F/B-Arch) are presented. A single centre retrospective sex comparative analysis of consecutive patients managed with F/B-Arch was conducted according to STROBE. Primary outcomes were sex comparative technical success, death, and cerebrovascular morbidity at 30 days. Kaplan-Meier estimates were used for follow up outcomes. Among 209 patients, 38.3% were women. Coronary artery disease (p < .001) and previous myocardial infarction (p= .01) were more common in women. Non-native proximal aortic landing was higher in women (women: 51.3%; men: 31.8%, p= .005) and the aortic dissection rate was lower (28.8% vs. 48.1%, p= .005). Proximal landing to Ishimaru zones showed no difference (zone 0: p= .18; zone 1: p= .47; zone 2: p= .39). Graft configurations were equally distributed. In total, 416 supra-aortic trunks were bridged. The median number of revascularisations per patient was two (interquartile range 1, 3), with no difference between sexes (p= .54). Technical success (women: 97.5%; men: 96.9%, p= .80), 30 day mortality rate (women: 10%; men: 9.3%, p= .86), and cerebrovascular morbidity (women: 11.3%; men: 17.1%, p= .25) were similar. Women presented more access related complications (women: 32.5%; men: 16.3%, p= .006), without affecting access related re-interventions (p= .55). Survival (women: 81.1%, 95% confidence interval [CI] 76.3 - 85.9%; men: 79.8%, 95% CI 76.0 - 83.6%) and freedom from re-intervention (women: 56.6%, 95% CI 50.4 - 62.8%; men: 55.3%, 95% CI 50.1 - 60.5%) at 12 months were similar (log rank, p= .40 and p= .41, respectively). Both sexes presented similar outcomes after F/B-Arch. Appropriate patient selection may decrease the effect of sex in F/B-Arch outcomes.

Physician Modified Fenestrated Endografts for Endovascular Aortic Arch Repair in Zone 0

This multicentre study aimed to assess the early and midterm outcomes of physician modified fenestrated endografts (PMEGs) for endovascular aortic arch repair in zone 0. Between 2018 and 2022, a retrospective study was conducted in three centres of consecutive patients undergoing endovascular aortic arch repair in zone 0 with PMEGs. Endpoints included technical success, 30 day mortality rate, major adverse events, secondary interventions, stent stability, target vessel patency, and overall survival. A total of 54 patients (mean age 63 years; 45 males) with aortic arch pathology were included, comprising aortic dissections (n= 32; 59%) and aortic arch aneurysms (n= 22; 41%). Technical success was 98%. One patient died from stroke within 30 days. Major adverse events included stroke (n= 4; 7%), retrograde type A dissection (RTAD) (n= 3; 6%), and acute kidney injury (n= 2; 4%). During a median follow up of 12 months, there were two deaths (4%) of unknown cause at one month and 1.5 months, and no aortic related death. Type Ia, type Ic, and type IIIc endoleaks were observed in two (4%), three (6%), and two (4%) patients, respectively. No vessel stenosis was observed. Re-intervention was required in 10 patients (19%). Estimates of overall survival, freedom from secondary intervention, and freedom from target vessel instability at one year were 94.2% (standard error [SE] 3.3%), 81.8% (SE 6.0%), and 92.0% (SE 4.5%), respectively. This study has demonstrated the efficacy of PMEGs for zone 0 endovascular aortic arch repair, with acceptable technical success and mortality rates. Stroke, RTAD, and re-intervention rates remain a concern for endovascular therapy. A larger population and long term outcomes are required to assess the safety and durability of this technique as a beneficial choice for endovascular aortic arch repair in specialised centres.

Branched and fenestrated endovascular aortic arch repair in patients with native proximal aortic landing zone

ObjectiveFenestrated and branched thoracic endovascular repair (f/bTEVAR) have been successfully applied in patients with diverse aortic arch pathologies. The aim of this study is to present the early and mid-term outcomes of patients with native proximal aortic landing (NPAL) managed with f/bTEVAR. MethodsA single-center retrospective analysis of patients with NPAL, managed with f/bTEVAR, between September 1, 2011, and June 30, 2022, was conducted. All patients were treated with custom-made devices (Cook Medical) with landing within Ishimaru zones 0 to 2. Primary outcomes were technical success, mortality, stroke, and retrograde type A dissection at 30 days. Follow-up outcomes were considered secondary. ResultsA total of 126 patients were included (69.8% males; mean age, 70.8 ± 4.2 years; 18.3% urgent). The main indications (60.4%) for repair were aortic arch (29.4%) and thoracoabdominal aortic aneurysms (31.0%). Seventy-two patients (57.1%) were managed with fTEVAR. Proximal landing in zone 0 and 1 was chosen in 97.6%. Technical success was 94.4%, and 30-day mortality was 11.9%. Strokes were diagnosed in 13.5% of patients and major strokes were identified in 7.9% cases. Retrograde type A dissection rate was 3.9%. The multivariate analysis confirmed landing in Ishimaru zone 0 as an independently related factor for stroke (P = .005), whereas stroke (P < .001), pericardial effusion (P < .001), and acute kidney injury (P < .001) were independently related to 30-day mortality. Mean follow-up was 17.5 ± 9.3 months. The estimated survival rate and the freedom from reintervention rate were 72.6% (standard error, 4.4%) and 46.4% (standard error, 6.0%) at 24-month follow-up, respectively. ConclusionsStroke rate after endovascular arch repair was alarming among patients with NPAL. Proximal landing to zone 0 was related to higher risk of stroke. Reinterventions were common within the 24-month follow-up.

Selective cerebral extracorporeal circulation-enhanced total endovascular arch replacement using in situ fenestration.

In this article, we present a newly designed cerebral perfusion technique during the in situ fenestration procedure with three covered stent placement in an endovascular total aortic arch repair of a 68-year-old male patient. This technique enables the endovascular repair of the ascending aorta and aortic arch pathologies with commonly available thoracic aorta stent grafts in a safer and more effective manner.

Novel chimney balloon technique to safeguard cerebral blood flow during total endovascular aortic arch repair

During endovascular total aortic arch repair by in situ fenestration, extra procedures are needed to sustain cerebral blood flow when targeting all three supra-aortic branches. Recently, our group successfully interposed a chimney balloon between the greater curvature of the aortic arch and an aortic stent to safeguard cerebral blood flow during total endovascular aortic arch repair.