Total Endovascular Arch Repair
Overview
Traditionally, treatment of aortic arch disease required open-heart surgery, involving an incision in the chest and the use of a heart-lung machine. Today, total endovascular aortic arch repair offers a minimally invasive alternative for selected patients. This advanced technique uses specially designed stent grafts. A stent graft is a small tube made of a metal framework covered with a durable fabric. It is placed inside the diseased portion of the artery to reinforce the vessel wall and restore normal blood flow.
Unlike conventional surgery, endovascular repair does not require opening the chest or using a heart-lung machine. Instead, the stent graft is delivered through the blood vessels, usually via small incisions in the groin, and positioned within the aortic arch. Once in place, it excludes aneurysms, dissections, or ulcers from the circulation while preserving blood flow to the brain and arms.
Indications
Total endovascular aortic arch repair may be an appropriate treatment option for patients with:
Aortic arch aneurysms (an enlargement or bulging of the aortic arch)
Aortic dissections involving the aortic arch
Medical conditions that make open or hybrid surgery high risk, such as advanced age, frailty, or significant underlying health problems
Before treatment, detailed imaging studies are performed to assess whether an endovascular approach is appropriate. Because these procedures are complex, they should be carried out in specialized centers with expertise in aortic disease, advanced imaging, and endovascular techniques.
Treatment decisions are typically made by a multidisciplinary team of specialists to ensure the most appropriate and personalized care for each patient.
Surgical Techniques
The procedure typically involves:
Accessing the arteries, usually through small incisions in the groin (femoral arteries), although other arteries in the neck or shoulder region may occasionally be used.
Positioning a customized stent graft within the aortic arch. The graft is specially designed with openings or branches to maintain blood flow to the arteries supplying the brain and arms.
Placing additional stents to connect the graft to these arteries, ensuring continuous blood flow to the head, neck, and upper limbs.
The surgery is generally performed under general anesthesia.
Risks and Complications
Although less invasive than open surgery, total endovascular arch repair carries specific risks, including:
Stroke: the most important potential complication, due to the close proximity of the arteries supplying the brain.
Endoleak: continued blood flow outside the stent graft and into the diseased portion of the aorta.
Stent graft complications: including movement, narrowing, blockage, or improper positioning of the device.
Access-site complications: such as bleeding, bruising, or injury to the blood vessels used to deliver the stent graft.
Spinal cord ischemia: a rare complication that can affect the blood supply to the spinal cord.
Kidney injury: occasionally caused by the contrast dye used during imaging and the procedure.
Follow-up
Following total endovascular aortic arch repair, regular follow-up is essential to monitor the stent graft and detect any potential complications at an early stage. These check-ups typically include clinical assessments and imaging studies performed at scheduled intervals. Although the frequency of follow-up visits may decrease over time, lifelong surveillance remains necessary to ensure the long-term safety and durability of the repair.