Anatomical Feasibility of a Thoracic Branched Endograft for Aortic Pathology Requiring Proximal Sealing in Zone 2

Type B acute aortic syndrome (AAS) and thoracic or thoraco-abdominal aortic aneurysm (TAA/TAAA) requiring proximal sealing in Ishimaru zone 2 have traditionally been managed with thoracic endovascular aortic repair (TEVAR), often combined with carotid subclavian bypass (CSB). The new Gore Thoracic Branch Endograft (TBE) facilitates the treatment of distal aortic arch lesions by including the left subclavian artery, yet maintaining its patency. This study aimed to assess the anatomical feasibility of TBE in patients treated or awaiting treatment for AAS or TAA/TAAA requiring proximal seal in zone 2.

This was a retrospective cohort analysis of all patients with AAS or TAA/TAAA referred to a single centre (January 2018 to March 2025) requiring proximal seal in zone 2 and with an indication for endovascular repair. Pre-operative computed tomography scans were reviewed. Anatomical feasibility (AF) was defined according to the TBE instructions for use. Iliac feasibility (IF) was determined based on iliofemoral diameters and calcification. True feasibility (TF) was the combination of AF and IF.

During the study period, 93 patients (78% male; median age at presentation 72 years [63,79]) were enrolled, of whom 65 (70%) had AAS and 28 (30%) had TAA/TAAA. TEVAR with CSB was performed in 53% (49/93), TEVAR with LSA coverage in 26% (24/93), and TBE in 5% (5/93); 16% (15/93) were awaiting endovascular repair. The overall AF for TBE was 92%, while TF was 85%, with seven patients showing hostile iliofemoral axes. There were no statistically significant differences in TBE AF (AAS 91% vs. TAA/TAAA 96%; p = .67) and TF (AAS 85% vs. TAA/TAAA 86%; p = 1.0) among patients with AAS and TAA/TAAA.

TBE showed high AF in both AAS and TAA/TAAAs requiring proximal sealing in zone 2. However, the elevated profile of the endograft may be considered a concern in patients with hostile iliofemoral axes.