Incidence of endograft rotation during endovascular aortic arch repair

This study aimed to evaluate the incidence, degree, and potential predictors of rotational deviation in custom-made triple-branch endografts (Cook Medical) deployed in the aortic arch, and to assess its impact on technical and clinical outcomes.

This single-center, retrospective study included 75 patients who underwent total endovascular aortic arch repair using custom-made Cook triple-branch devices between October 2018 and April 2025. Endograft rotational deviation was assessed by comparing intended and actual branch positions using clock-face orientation with three-dimensional centerline reconstruction. Anatomic variables, including arch, aortic, and iliac tortuosity, and device specifications, were analyzed to identify potential predictors of rotation. Patients were stratified into three groups based on total rotation: <20°, 20°-40°, and >40°.

Most patients (74.7%) had minimal rotation (<20°), whereas 17.3% had moderate (20°-40°) and 8% severe (>40°) rotation. No significant differences in arch anatomy, aortic diameter, or graft dimensions were associated with rotation. However, higher iliac tortuosity index (P = .041) and smaller brachiocephalic trunk branch diameter (P < .001) were significantly correlated with severe rotation. Arch tortuosity index did not significantly (P = .088) impact graft rotation. Technical success was achieved in 96% of patients, unaffected by rotational deviation. Although early stroke incidence was higher in patients with severe rotation (33.3%), this did not reach statistical significance (7.1% vs 0% in mild and moderate rotation, P = .089). Midterm outcomes, including mortality and reintervention, were comparable across groups.

The delivery system of the triple-branch Cook custom-made devices demonstrates excellent precision, with limited graft rotation in the majority of cases. Although there was a trend toward arch tortuosity in device rotation, iliac tortuosity was significantly associated with rotational deviation. Preoperative assessment of such anatomical factors may enhance procedural planning and reduce intraoperative challenges.