Total endovascular arch repair: should it be the first-line option in the elective treatment of aortic arch aneurysms?

BACKGROUND: Although the traditional standard of care for aortic arch aneurysms is open surgical arch replacement, this approach usually requires sternotomy, cardiopulmonary bypass and hypothermic arrest. Even among the subset of patients fit for open surgery, it is associated with a pooled mortality and stroke rate of around 5%. Nowadays, a multidisciplinary team of vascular and cardiac surgeons is mandatory to determine the best, individualised treatment for each patient. CASE REPORT: A 70-year-old male was incidentally diagnosed with an asymptomatic saccular aortic arch aneurysm. After a discussion with vascular and cardiac teams, a total endovascular arch repair was decided. Percutaneous access was obtained to the right femoral and axillary arteries, the left brachial artery, and the left femoral vein. Only the left carotid artery was surgically exposed. A Cook custom-made three-inner-branched stent graft was deployed under temporary inferior vena cava occlusion. Two anterograde branches for the innominate trunk (bridged with a 12 mm-diameter iliac limb) and the left carotid artery (bridged with a 6 mm Bentley Begraft balloon-expandable covered stent), and a retrograde branch with a preloaded catheter for the left subclavian artery (bridged with a 10 mm Gore Viabahn self-expandable covered stent, relined with a 10 mm Bentley Begraft due to a kink) were implanted. The procedure was successfully completed, and the patient was discharged after three days. Computed tomography angiography at three months demonstrated aneurysm exclusion, patency of the three supra-aortic branches and absence of cerebral ischemic lesions. CONCLUSION: In the elective setting, a triple-branch custom-made device enables total endovascular arch repair without the need for surgical revascularisation, thereby reducing invasiveness and morbidity, even in non-high-risk patients with suitable anatomy. A third branch also allows upper-extremity access for future visceral branch endovascular interventions.