Endovascular Management of Aortic Arch Diseases: Current Status and Future Trends : Cardiology Discovery

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Endovascular Management of Aortic Arch Diseases: Current Status and Future Trends

Shu, Chang1,2,3,*; Li, Jiehua2,3; Luo, Mingyao1; Li, Quanming2,3; Fang, Kun1

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Cardiology Discovery 2(4):p 263-268, December 2022. | DOI: 10.1097/CD9.0000000000000080
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Treatment of aortic arch (AA) diseases (eg, aortic aneurysms, pseudoaneurysms, aortic dissection, penetrating aortic ulcers, and intramural hematomas) is formidably challenging for surgeons. Although conventional open repair of the AA remains the “gold standard,” it requires cardiopulmonary bypass and deep hypothermic circulatory arrest, and can lead to significant morbidity and mortality despite improvements in surgical techniques.[1–3] Thus, researchers have been seeking less invasive therapeutic modalities for AA diseases. Several innovative endovascular techniques have been developed to address the anatomic challenges of the AA.

Thoracic endovascular aortic repair (TEVAR) was first used to treat thoracic aortic aneurysms in 1994.[4] Gradually, it has become first-line treatment for descending aortic diseases. The indications for TEVAR have expanded with the continuous development of interventional devices and techniques. Also, endovascular management of lesions involving the AA has been explored and practiced gradually. The vital branches to the brain, AA curvature, and high blood flow increase the difficulties in TEVAR for AA diseases significantly. Different strategies have been proposed to preserve supra-aortic branches in TEVAR: hybrid technique, “chimney” technique, fenestration technique (including custom-made fenestrated or “scalloped” stent grafts, in situ fenestration, and physician-modified fenestration), and branched stent grafts.[5,6] Now, surgeons have various of options to treat patients who are not suitable for open surgery.

Here, we briefly review the current status and progress of endovascular repair of the AA, and envision future prospects. Although several treatment strategies are available, evidence is still lacking concerning which is the optimal option for specific AA diseases.

Hybrid technique

The hybrid technique combines traditional open surgery and endovascular repair, thereby providing a new option for AA reconstruction. Four main types of hybrid AA reconstruction are available.[7]

Type-I hybrid repair requires the ascending aorta to be healthy. Then, a sternotomy with bypass of the supra-aortic trunks from the ascending aorta is undertaken, and the aortic stent graft can be deployed proximally in the ascending aorta. Type-II hybrid repair is completed with replacement of the ascending aorta (with or without treatment of the aortic root), debranching of supra-aortic trunks, and deployment of an aortic stent graft from the ascending aorta to the descending aorta. Type-III hybrid repair is carried out with replacement of the ascending aorta (with or without treatment of the aortic root) and AA (with or without the “elephant trunk” technique), and the distal lesions in the descending aorta are treated with an endovascular strategy. The 3 types stated above involve total reconstruction of the AA. Type-IV hybrid repair is based on partial reconstruction of the AA. Type-IVa hybrid repair is undertaken with bypass of 1 or 2 supra-aortic trunks from the ascending aorta. Type-IVb hybrid reconstruction is done with cervical extra-anatomic revascularization, and a sternotomy is not required. Figure 1 shows the imaging of a patient with a thoracic aortic aneurysm who underwent TEVAR combined with left subclavian artery (LSA) to left common carotid artery (LCCA) bypass, which is a type-IVb hybrid reconstruction.

Figure 1::
TEVAR with extra-anatomical bypass. (A) CTA showed the thoracic aortic aneurysm with aortic arch involvement; (B) Post-operative CTA showed the lesion was repaired by TEVAR combined with left subclavian artery to left common carotid artery bypass. CTA: Computed tomography angiography; TEVAR: Thoracic endovascular aortic repair.

The aim of the hybrid technique is to simplify surgical procedures and reduce the risk of intraoperative injury. Type-I repair and type-IV hybrid repair do not require replacement of the ascending aorta, and so aortic cross-clamping and cardiopulmonary bypass are avoided, whereas type-IVb hybrid repair avoids a sternotomy. Type-II hybrid repair does not require deep hypothermic circulatory arrest and avoids the surgical exposure and replacement of the AA. Type-III hybrid repair provides a less invasive option to treat lesions in the distal descending aorta. A major concern about the hybrid technique is retrograde type-A aortic dissection, which can be caused by clamping of the aorta or compliance mismatch between the stent graft and aorta.[8] Retrograde type-A aortic dissection has been reported in 6% of patients if a stent graft is deployed in the native ascending aorta following debranching, and mortality rate can be as high as 42%.[9] Other concerns include stroke, paraplegia, and endoleaks necessitating a secondary intervention.[10–12]

Several research teams have reported favorable outcomes of hybrid repair of the AA. In a large, single-center retrospective study by Zhang et al,[13] 815 patients with DeBakey type-I dissection underwent conventional open repair and 122 underwent type-II hybrid reconstruction. The hybrid group showed a slightly lower early mortality and complications (9.2% vs. 17.4%, P = 0.073; 15.6% vs. 25.7%, P = 0.066) compared with those undergoing conventional open repair. According to a retrospective analysis by Iba et al,[14] although the surgical risk was significantly higher in a hybrid group compared with that in a group undergoing conventional open repair, there was no significant difference in early mortality or 3-year survival rates. Also, they found that the hybrid group had a shorter duration of stay in the intensive care unit, but a higher prevalence of reintervention. In a systematic review by Moulakakis et al,[15] incorporating 26 reports on the hybrid technique, the authors found that the prevalence of technical success was 92%, perioperative mortality was 11.9%, cerebrovascular accidents was 7.6%, and irreversible ischemia of the spinal cord was 3.6%. Hybrid repair of the AA continues to show a significant prevalence of morbidity and mortality. Nevertheless, it is less invasive than conventional open repair, and high-quality randomized controlled trials are required to compare the safety and efficacy between these 2 treatment strategies.[16]

Chimney technique

The chimney technique (also called the “parallel stent graft” or “double-barrel” technique) is an increasingly popular option for treating AA diseases. A stent graft deployed parallel to a thoracic aortic endograft can be used to maintain the patency of the supra-aortic branch and extend the landing zone proximally in TEVAR. In 1999, Greenberg et al[17] were the first to report implantation of a renal stent parallel to an aortic stent graft to rescue the renal artery for treatment of an abdominal aortic aneurysm. In 2002, Criado et al[18] used this technique to rescue an unexpectedly covered LSA in TEVAR. In 2007, this technique was introduced comprehensively in TEVAR.[19] As shown in Figure 2, chimney stents can be implanted to preserve blood flow in the innominate artery and LCCA, and the aortic stent graft landed proximally in the ascending aorta.

Figure 2::
TEVAR with double chimney technique. (A) CTA showed the aortic dissection with innominate artery involvement; (B) The patient was successfully treated with TEVAR combined with chimney stents implanted in innominate artery and left common carotid artery. CTA: Computed tomography angiography; TEVAR: Thoracic endovascular aortic repair.

The chimney technique offers the advantages of using standard “off-the-shelf” devices with relatively simple manipulation. The chimney technique has been accepted in emergency TEVAR as well as for patients with a high surgical risk or challenging anatomy of the AA.[20–22] The main concern about the chimney technique is the risk of type-Ia endoleak due to the gutters being alongside the aortic stent graft, chimney stent, and thoracic aortic wall. Various approaches have been proposed to decrease the risk of type-Ia endoleak: use of covered chimney stents; sufficient overlapping between the aortic stent and chimney stent; adequate oversizing of the aortic stent graft; appropriate angioplasty using a “kissing balloon.” Recently, a novel gutter-free chimney stent graft named “Longuette” comprising an inner stent and outer skirt fabric was developed to reduce the risk of type-Ia endoleak after TEVAR using the chimney technique.[23,24] Some type-Ia endoleaks can be treated conservatively and seal spontaneously during follow-up, and embolizing the gutter with coils or glue has been reported to treat a persistent type-Ia endoleak.[25]

Several research teams have reported favorable outcomes of treating AA diseases with the chimney technique. Wang et al[26] reported a series of 122 patients with 143 supra-aortic vessels reconstructed using the chimney technique, and the midterm outcome was satisfactory. The prevalence of perioperative mortality was 0.8%, type-Ia endoleak was 10.7%, type-II endoleak was 4.9%, secondary intervention was 1.7%, and all chimney stents were patent during follow-up. Another research team reported a single-center experience of 226 cases treated with the chimney technique.[27] In that study, the prevalence of an immediate type-Ia endoleak was 16%, 30-day mortality was 2%, and morbidity was 4%, and chimney-stent occlusion occurred in 3% of patients. Ahmad et al[28] conducted a systematic analysis incorporating 11 publications involving 373 patients receiving 387 chimney stents. They found that the overall prevalence of a type-I endoleak was 9.4%, 30-day mortality was 7.9%, reintervention was 10.6%, major stroke was 2.6%, early patency was 97.9%, late patency was 92.9%, and retrograde type-A dissection occurred in 1.8% of patients. TEVAR with the chimney technique has been regarded as a feasible and effective strategy to treat AA diseases. Nevertheless, concerns about complications such as a type-Ia endoleak, chimney-stent occlusion, and cerebrovascular events remain.

Fenestration technique

The fenestration technique includes custom-made fenestrated or scalloped stent grafts, in situ fenestration, and physician-modified fenestration (also known as “on-the-table” fenestration). It is another feasible endovascular strategy to repair AA diseases. Only a few studies have focused on the outcome of custom-made fenestrated or scalloped stent grafts in treatment of AA diseases, and their application is limited by technical difficulties and the time needed for manufacture.[29–31]In situ fenestration and physician-modified fenestration have been accepted widely because they can take advantage of off-the-shelf stent grafts. Compared with the chimney technique, there is no risk of gutter endoleak for the fenestration technique. However, changes in mechanical factors and the structural instability of the aortic stent graft caused by fenestration are the main concerns.

In situ fenestration

In situ fenestration was first described by McWilliams et al.[32] It has become a useful way to reconstruct supra-aortic branches using a retrograde needle or energy-based device (laser or radiofrequency).[33] As shown in Figure 3, after deployment of the aortic stent graft, in situ fenestration can be undertaken using a retrograde needle to puncture the aortic stent graft. Then, an angioplasty balloon is used to dilate the hole, and a covered stent is placed within the orifice. The success of this technique is highly dependent on the take-off angle of the targeted branch because a small take-off angle (<45°) increases the difficulty of making the fenestration.[34] Application of in situ fenestration is usually limited to preserve the LSA and/or LCCA because temporary occlusion of the covered supra-aortic branch is required during the procedure.

Figure 3::
TEVAR with in situ fenestration. (A) After deployment of the aortic stent graft, in situ fenestration was undertaken using a retrograde needle to puncture the aortic stent graft; (B) Post-operative CTA showed the left subclavian artery was successfully preserved. CTA: Computed tomography angiography; TEVAR: Thoracic endovascular aortic repair.

Luo et al[35] reported a series of 50 patients who underwent in situ fenestration to revascularize the LSA during TEVAR. In that study, the prevalence of technical success was 96%, type-III endoleak was 8%, open reintervention during follow-up was 4%, and there was no perioperative major adverse event nor type-I endoleak. In a retrospective analysis of a large series of patients by Li et al,[36] 148 patients were treated with in situ fenestration during TEVAR. In their study, the prevalence of a successful procedure was 97.3%, endoleak was 4.7%, retrograde dissection was 2%, perioperative stroke was 3.4%, and 30-day mortality was 2.9%. These studies demonstrated that in situ fenestration could be a safe and effective way to treat AA diseases and had a low prevalence of complications, but the long-term durability is largely unknown.

Physician-modified fenestration

TEVAR with physician-modified fenestration has become a popular option to treat AA diseases. The procedure involves part unsheathing of the aortic stent graft device and fashioning of fenestrations, reloading of the device into the delivery system, deployment of the stent in the targeted site, and implantation of a bridging stent in the targeted supra-aortic branch through a modified fenestration [Figure 4]. This method can also take advantage of conventional stent grafts with relatively simple procedures. Also, the radiopaque markers on the aortic stent graft can be used to guide fenestration and location for branch arteries.[37] The mean duration of the procedure (from the first to the last use of digital subtraction angiography) was reported to be 22.8 minutes in a specialist vascular center, and several research teams have reported satisfactory outcomes using this technique.[38–41] However, remote access from the femoral artery and anatomic factors (eg, tortuosity and/or rotation of the AA) can lead to difficulties in orientation of the aortic stent and precise matching of the fenestration to supra-aortic branch arteries, so preoperative assessment and planning are crucial.

Figure 4::
TEVAR with physician-modified fenestration. (A) Physician-modified fenestration was applied to the aortic stent graft before its implantation; (B) Post-operative CTA showed the left subclavian artery was successfully preserved. CTA: Computed tomography angiography; TEVAR: Thoracic endovascular aortic repair.

Chassin-Trubert et al[42] reported a series of 54 consecutive patients receiving scalloped or fenestrated physician-modified stent grafts to preserve the LSA. In that study, the prevalence of technical success was 94% (with 3 (6%) LSAs covered unintentionally), type-Ia endoleak was 2%, type-II endoleak was 4%, perioperative mortality was 7%, and all LSAs remained patent during follow-up. The same research team recently reported on a series of 50 patients receiving double-fenestrated physician-modified stent grafts to preserve all supra-aortic branches.[43] The outcomes were similarly satisfactory: the prevalence of technical success was 94%, type-II endoleak was 4%, 30-day mortality was 2%, and reintervention was 8%. Zhang et al[44] conducted a comparative study of physician-modified fenestration (110 cases) and chimney technique (364 cases). They concluded that TEVAR with physician-modified fenestration seemed to have more favorable short and midterm outcomes than those using the chimney technique. Though physician-modified fenestration has been shown to be a valuable option in endovascular repair of the AA, concerns remain about the long-term durability due to off-label modification of the aortic stent graft.[45]

Branched stent graft

Use of a branched stent graft is an evolving technology to treat AA diseases. In 1996, Inoue et al[46,47] first devised a novel branched stent graft to treat AA diseases without the need for extra-anatomical bypass. Tazaki et al[48] reported their 10-year experience of using the branched Inoue stent graft with a mixed number of branches, in which 89 patients were involved. Their study showed acceptable outcomes with regard to the prevalence of 30-day mortality (4.5%) and 5-year aneurysm-related death (7%), but a significant prevalence of periprocedural stroke (16%) was also documented. Besides the Inoue stent graft, various off-the-shelf branched aortic stent grafts are being developed and used in clinical trials.[5,49] Single-branch devices include the MONA LSA (Medtronic, Santa Rosa, California, USA),[50] Nexus device (Endospan, Herzlia, Israel),[51] thoracic branch endograft (WL Gore, Flagstaff, Arizona, USA),[52] and Castor device (Microport Medical, Shanghai, China).[53] Multi-branch devices include the Bolton Relay Plus branched arch endograft (Terumo Aortic, Sunrise, Florida, USA)[54] and Zenith branched stent graft (Cook Medical, Bloomington, Indiana, USA).[55]

The Castor branched endograft is the only commercially available branched stent graft in China. A Castor branched stent can be deployed to preserve the LSA [Figure 5]. Recently, Jing et al[56] reported the outcomes of a multicenter prospective trial using a Castor branched endograft to treat 73 patients with aortic dissection involving the LSA. The outcomes were encouraging: the prevalence of technical success was 97%, endoleak was 5%, mortality within 1 year was 5%, mortality within 6 years was 7%, and follow-up patency of the branch was 93%. The same research team also reported their successful experience of using a customized branched stent graft to treat AA diseases, in which multiple supra-aortic branches could be preserved by combination of a single branched stent graft and single or double fenestration.[57,58]

Figure 5::
TEVAR with Castor branched stent graft. (A) CTA showed the thoracic aortic aneurysm with limited proximal landing zone; (B) The lesion was successfully excluded with a Castor branched stent graft and the left subclavian artery was also preserved. CTA: Computed tomography angiography; TEVAR: Thoracic endovascular aortic repair.

The branched stent seems an ideal option for endovascular repair of the AA because it fits the AA anatomy better compared with use of the chimney technique and fenestration technique, thereby reducing the risk of endoleaks as well as providing structural integrity. However, its custom-made characteristic, complexity in manipulation, and association with a high prevalence of stroke[59,60] have limited its use. More researches and improvement are needed in the future.

Summary and prospects

Endovascular repair of the AA has expanded rapidly in recent years with the improvement of TEVAR devices and techniques. Various therapeutic modalities are available for patients who are poor candidates for open surgery. The optimal treatment strategy should be developed in a patient-individualized approach based on the disease and anatomy of the AA, patient characteristics, and experience of surgeons. Recently, our research team proposed the “HENDO” concept to treat AA diseases individually based on the hybrid technique (H), endovascular repair (END), and open surgery (O).[61] The HENDO team should comprise professionals in hybrid repair, endovascular repair, open surgery, cardiovascular anesthesia, and genetics. They should work collaboratively to provide the ideal treatment that benefits the patients most. The HENDO concept is in accordance with the recent consensus reached by the European Association for Cardio-Thoracic Surgery and the European Society for Vascular Surgery, which recommends multidisciplinary collaboration of an entire aortic team.[62]

Recent studies have demonstrated acceptable early and midterm outcomes of different strategies in endovascular repair of the AA, but the evidence of long-term safety and efficacy are lacking. For patients with a low risk for open surgery (especially young patients with connective-tissue disorders), endovascular treatment should be considered judiciously. Studies using large patient cohorts, long-term follow-up, and multicenter prospective randomized controlled trials focusing on current strategies are needed. Further improvement and innovation of devices and techniques are also required. Endovascular repair of the AA is promising to provide safe and minimally invasive therapy for patients with AA diseases.


This work was supported by the National Natural Science Foundation of China (81870345 and 81800400).

Conflicts of interest


Editor note: Chang Shu is an Editorial Board Member of Cardiology Discovery. The article was subject to the journal’s standard procedures, with peer review handled independently of this editor and his research groups.


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Aortic diseases; Endovascular aortic arch repair; Hybrid repair; Chimney technique; Fenestration technique; Branched stent graft

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