Total endovascular aortic arch repair has emerged as an innovative alternative to open surgery for patients with aneurysms in this anatomically complex region. While conventional surgery remains the gold standard due to its proven durability, it carries significant risks, with mortality rates ranging from 5% to 25.6%, as well as a high incidence of severe neurological complications.

The endovascular approach provides a less invasive option that reduces surgical trauma, shortens recovery time, and expands therapeutic alternatives for high-risk patients who would otherwise be considered inoperable. One of its main advantages lies in the ability to customize devices, particularly through company-manufactured devices (CMDs) and surgeon-modified endografts (PMEGs), enhancing adaptability to complex anatomies and potentially improving clinical outcomes.

In this study, patients were selected based on specific anatomical and clinical criteria. A retrospective review was conducted on nine cases treated between 2018 and 2021 at a single center, analyzing technical success, complication rates, and the need for reinterventions. The ascending aorta had to have a diameter of 38 mm or less to ensure proper graft sealing. The proximal landing zone had to be at least 40 mm (or 20 mm in patients with prior surgical grafts) to provide a secure anchoring of the device. Additionally, an arch angulation of up to 60 degrees was considered to facilitate navigation and precise deployment of the graft. The included patients had a mean age of 73 years and multiple comorbidities, such as chronic kidney disease and a history of cardiac or ascending aortic surgery.

The primary vascular access was through the femoral artery, with carotid or brachial access used in selected cases to optimize device positioning. The endografts used featured branches or fenestrations to maintain perfusion of the supra-aortic trunks. Fluoroscopic guidance played a crucial role in ensuring proper device alignment, particularly in cases treated with PMEGs, where self-expanding covered Viabahn® stents were employed to reinforce the internal branches and improve adaptability in complex anatomies.

Technical success was achieved in 100% of the nine treated patients, with no in-hospital mortality or major neurological complications. However, 33% of cases presented significant adverse events, including vascular access complications in 22% of patients and acute kidney injury in 11%.

One of the most notable findings was the high incidence of postoperative endoleaks, observed in 66% of patients. Most were type I, which raises concerns as they may compromise graft sealing and promote aneurysm progression. Although most endoleaks resolved spontaneously, their frequency raises questions about the long-term durability of the procedure.

A case of late graft infection was reported, requiring conversion to open surgery and resulting in the patient’s death 239 days postoperatively. During a mean follow-up of 358 days, target vessel patency remained at 100%, suggesting favorable early outcomes. Nevertheless, the authors emphasize that larger studies with extended follow-up are needed to evaluate the safety and durability of this technique.

COMMENTARY:

This study provides valuable insights into an evolving technique within endovascular surgery, but it presents several limitations that must be considered before its widespread adoption.

The small sample size and highly selective patient population raise concerns about the applicability of the results to routine clinical practice. Since the procedures were performed at a high-volume referral center with carefully selected patients, their reproducibility in hospitals with less experience in advanced endovascular techniques remains uncertain.

Another concerning aspect is the high rate of early endoleaks, observed in two-thirds of the patients. Although many were transient, the presence of type I endoleaks is particularly relevant, as they can compromise endograft sealing and increase the risk of aneurysm expansion, potentially requiring additional reinterventions. In other segments of the aorta, techniques such as fenestrated and branched endovascular repair have demonstrated a reduction in this issue, but their adaptation to the aortic arch has not yet been fully explored.

The relatively short follow-up of this study is another limiting factor. With a mean duration of only 358 days, it is challenging to assess the durability of this approach compared to open surgery, which has demonstrated long-term stability over decades. Without extended follow-up data, it remains unclear whether total endovascular aortic arch repair can offer comparable outcomes in terms of longevity and stability. Additionally, the durability of PMEGs remains uncertain, as modifications performed outside the original design may introduce variability in outcomes.

In conclusion, total endovascular aortic arch repair represents a promising minimally invasive alternative for high-risk patients, but its definitive role in clinical practice remains unclear. The high rate of early endoleaks, the small patient cohort, and the limited follow-up highlight the need for multicenter studies with at least 5 to 10 years of follow-up to establish with greater certainty its long-term safety and efficacy. Until such data become available, open surgery remains the reference standard against which this evolving technique must be compared.

REFERENCE:

Lee KB, Porras-Colon J, Scott CK, Chamseddin K, Baig MS, Timaran CH. Early results and feasibility of total endovascular aortic arch repair using 3-vessel company-manufactured and physician-modified stent-grafts. J Endovasc Ther. 2024;31(6):1197-1207. doi:10.1177/15266028231163069.