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Introduction: The treatment of chronic postdissection aneurysms of the aortic arch is a challenge. This study aims to describe false lumen management after aortic arch endovascular repair of post-type A dissection aneurysms treated with a branched endograft., Methods: In this single-center retrospective observational study, all consecutive patients undergoing endovascular treatment of aneurysmal degeneration of chronic type A aortic dissections following open repair were enrolled. The primary endpoint was maximal aortic diameter evolution measured on computed tomography angiography (CTA) performed during follow-up. Secondary endpoints included procedural success, aortic re intervention, and remodeling during follow-up., Results: Between January 2017 and June 2020, 22 patients underwent endovascular branched arch repair for post type A dissection aneurysms. Technical success was 100%. Thirteen patients (59%) had dissection involvement of at least 1 supra-aortic vessel. Midterm follow-up CTA was performed for 20 patients, 23.1 (±13.3) months after the procedure. Maximal aortic diameter at the level of the repair was decreasing in 13 (65%) patients, increasing in 2 (10%) patients, and no change was observed in 5 (25%) patients. During follow-up, 7 patients (35%) required aortic reintervention. Thoracic candy plugs were implanted for distal false lumen occlusion in 15 patients and associated with a high rate of complete remodeling (6/15 patients, 40%)., Conclusion: Arch branch endografting of aneurysmal evolution of a post type A dissection aortic arch is a safe and feasible option in experienced hands. Candy plug use in favorable anatomies seems to be associated with accelerated remodeling of the aorta., Clinical Impact: There are currently no recommendations on dissected supra- aortic vessels management and the use of thoracic aorta false lumen occlusion devices during endovascular repair of chronic post dissection aneurysm of the aortic arch with branched endografts. Based on our clinical experience reported in the current manuscript, we propose a treatment algorithm for the management of the false lumen in this setting., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: SH is a consultant for GE healthcare and Cook Medical.

Background: Long-term outcomes after acute type A aortic dissection (ATAAD) are related to remodelling of the descending thoracic aorta and aortic reinterventions. We compared the impact of an extensive repair at the index procedure using the Frozen Elephant Trunk (FET) technique, versus a conventional arch repair, on long-term remodelling of the descending thoracic and reintervention related to the aorta., Methods: Consecutive patients who underwent conventional arch repair (conventional group) or FET repair (FET group) for an ATAAD from September 2018 to November 2021 were included. Patients who died before discharge or were lost to follow-up prior to the first appointment were excluded from the analysis. Preoperative and postoperative computed tomography angiography was reconstructed and diameter of the true/false lumen of the remaining aorta was compared up to 1 year. Negative (increased total diameter ≥ 5 mm) aortic remodelling was collected for each computed tomography angiography, as well as aortic reinterventions. Comparison of demographic, anatomical, and perioperative complications data were performed using Wilcoxon test for continuous variables or Chi-square test for categorical covariates. The Kaplan-Meier method estimator was used to assess survival rates. The Log rank test was used to compare survival curves between the 2 groups., Results: Thirty nine patients were included, 22 in the conventional group and 17 in the FET group (82% males, mean age 60 ± 12 years). In the FET group, distal anastomosis was performed in zone 0 or 1 for 82% of patients using the simplified delivery technique. Median maximum preoperative descending aortic diameter was larger in the FET group (33 mm [30; 37] vs. 30 mm [28; 32] [P = 0.0172]). At 30 days, the rate of negative remodelling on the descending thoracic aorta was significantly higher in the conventional group (50%) than in the FET group (8%, P = 0.02). At 1 year, Kaplan-Meier analysis shown a freedom from descending aortic negative remodeling of 35.1% (95% confidence interval (CI) 18.7-66.1%) in conventional group and 44.9% (CI 95% 26.1-77.2%) in FET group with no significant difference. However, early negative remodelling was observed for the conventional group. Within a year, freedom from reintervention was observed for 74.4% (95% CI 57.1-97%) of patients in the conventional group and 75.5 (95% CI 57.1-99.7%) of patients in the FET group with no significant difference., Conclusions: Negative evolution of descending aorta remains a challenge after ATAAD. An extensive repair using the FET technique during the index procedure seems to be associated with satisfying short-term remodelling of descending aorta., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: We evaluated the outcomes of total endovascular aortic arch repair using three-vessel inner branch stent-grafts for aneurysms and chronic dissections., Methods: We reviewed the clinical data and outcomes of consecutive patients treated by total endovascular aortic arch repair at eight academic centers using three-vessel inner branch stent-grafts (William Cook Europe, Bjaeverskov, Denmark) from 2016 to 2019. All patients received three-vessel designs with two antegrade and one retrograde inner branch, which was used to incorporate the innominate, left common carotid, and left subclavian arteries. The antegrade inner branches were accessed via a carotid or an upper extremity approach. A preloaded catheter was used for access to the retrograde left subclavian artery branch via a transfemoral approach. The endpoints were technical success, mortality, major adverse events, any stroke (minor or major) or transient ischemia attack, secondary interventions, target vessel patency, target vessel instability, aneurysm-related mortality, and patient survival., Results: A total of 39 patients (31 men [79%]; mean age, 70 ± 7 years) had undergone treatment of 14 degenerative (36%) and 25 chronic (64%) postdissection arch aneurysms. The clinical characteristics included American Society of Anesthesiologists class ≥III in 28 patients (95%) and previous median sternotomy for ascending aortic repair in 28 patients (72%). The technical success rate was 100%. Two patients had died in-hospital or within 30 days (5%), and two patients had experienced a stroke (one minor). The combined mortality and any stroke rate was 8% (n = 3). Major adverse events occurred in 10 patients (26%), including respiratory failure in 4 (10%) and estimated blood loss >1 L, myocardial infarction, and acute kidney injury in 2 patients each (5%). The median follow-up was 3.2 months (interquartile range, 1-14 months). Of the 39 patients, 12 (31%) required secondary interventions to treat vascular access complications in 5, endoleak in 6 (three type II, one type Ic, one type Ia/Ib, one type IIIa), and target vessel stenosis in 1 patient. At 1 year, the primary and secondary patency rates and freedom from target vessel instability were 95% ± 5%, 100%, and 91% ± 5%, respectively. Freedom from aortic-related mortality and patient survival was 94% ± 4% and 90% ± 6%, respectively., Conclusions: The findings from the present multicenter global experience have demonstrated the technical feasibility and safety of total endovascular aortic arch repair for aneurysms and chronic dissections using three-vessel inner branch stent-grafts. The mortality and stroke rates compare favorably with those after open surgical repair in a higher risk group of patients. However, the rate of secondary interventions was high (31%), emphasizing need for greater experience and longer follow-up., (Copyright © 2021. Published by Elsevier Inc.)

Objective: Coverage of the left subclavian artery (LSA) origin during thoracic endovascular aortic repair (TEVAR) is associated with increased neurologic complications. Our group is involved in the development of an off-the-shelf (OTS) thoracic endograft incorporating a left common carotid artery (LCCA) scallop and a retrograde inner branch for LSA perfusion. This study aimed to evaluate the arch morphology of patients treated by TEVAR and requiring LSA coverage to determine the applicability of this OTS device., Methods: The preoperative anatomy of consecutive patients from three separate cohorts treated with TEVAR with LSA coverage was studied. High-quality preoperative computed tomography angiography images were analyzed on an imaging workstation. Location of the origin of the supra-aortic trunks and their anatomic relationship were depicted in all patients; the LCCA origin was set as reference point. We determined the proportion of arch morphology in our cohort of patients eligible for this OTS device configuration., Results: There were 196 patients included in this study, 132 in the dissection cohort and 64 in the aneurysm cohort. The median length from the lower margin of the LCCA to the proximal aspect of the pathologic process was 25.0 mm (18.2-35.2 mm), with 68.4% (n = 134) of our cohort presenting with a proximal sealing zone length >20 mm. The median LCCA-LSA distance was 20.8 mm (16.6-25.4 mm). The median clock position of the LSA from the LCCA was -10 minutes (-30 to 0 minutes). In total, 127 patients (64.8%) could have been treated with the current OTS branched TEVAR configuration; 59 were excluded for proximal neck length distal to the LCCA <20 mm and 10 because of the clock position of the LCCA, and 9 first required a vertebral artery transposition., Conclusions: The low variability of LSA and LCCA locations in patients with distal aortic arch disease offers wide applicability of a new standardized thoracic branched endograft., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

This article reviews endovascular management of chronic post-dissection aneurysms of the aortic arch. Therapeutic strategies intended for this complex aortic condition are evolving rapidly to allow the treatment of various hostile aortic anatomy and frail patients. Principles, technical considerations, devices and outcomes of each technique are reviewed and summarized. Hybrid repair offer similar early mortality and stroke rates compared to open conventional surgery. Arch chimney and other parallel graft techniques present poor long term outcome, and should be limited to emergency situations where no other option is available. Fenestrated stent-grafting is subjected to many technical challenges in aortic arch due to difficulties in stent-graft orientation and fenestration positioning. In situ fenestration is an off-label technique that should only be used as an emergency bailout maneuver, considering that temporary coverage of supra aortic trunk vessel and its long-term durability raise concern. Finally, in experienced hands and appropriate anatomic conditions, arch branched graft technology has shown itself to be a safe and effective alternative to open conventional surgery. No randomized controlled trials have yet compared total endovascular aortic arch repair with hybrid techniques and open arch repair. The management of chronic post-dissection aneurysms of the aortic arch is challenging, decision-making and interventions should continue to be performed in high-volume centers with a dedicated aortic team with an expertise in both open and endovascular repairs.