[Strategies for aortic arch branch reconstruction during thoracic endovascular aortic repair]

Objective: To explore optimal approaches and strategies for supra-arch branch reconstruction during endovascular repair of aortic arch diseases. Methods: This retrospective study included 50 patients who underwent endovascular aortic arch repair with supra-arch branch reconstruction in the Department of Vascular Surgery, Zhongshan Hospital, Fudan University, from May 2023 to September 2024. The cohort comprised 40 males and 10 females with an age of (65.1±11.4)years (range:35 to 82 years). Underlying pathologies included aortic dissection in 16 patients (acute, n=5; chronic, n=8; post-TEVAR endoleak, n=3), aneurysm in 26, pseudoaneurysm in 1, intramural hematoma in 1, penetrating ulcer in 4, aberrant subclavian artery aneurysm in 1, and Kommerell diverticulum in 1. Surgical strategies were determined after multidisciplinary discussion, considering patients'overall condition, aortic arch anatomy, lesion location, spatial relationship with arch branches, vessel diameters and angles, available stent types, and proximal/distal landing zones. Baseline characteristics, operative details, and postoperative complications were recorded. Six-month survival rate and freedom from major aortic-related adverse event rate were analyzed using Kaplan-Meier methods. Results: Among 50 patients, 75 branches were reconstructed using various techniques, including debranching (2 cases, 4.0%); in-situ fenestration (ISF, 20 cases, 40.0%); branched endovascular aortic repair (4 cases, 8.0%); physician-modified endografting (17 cases, 34.0%); chimney technique (2 cases, 4.0%); and ISF combined with the chimney technique (5 cases, 10.0%). Technical success was achieved in 98.0% (49/50) of patients. Two perioperative deaths occurred because of cerebral hemorrhage (1 case) and spinal cord ischemia (1 case), respectively. The median follow-up period (M(IQR)) was 7.0(6.0) months(range:1.0 to 19.0 months). The 6-month follow-up survival rate was 96.0%, and the freedom from aortic-related adverse events rate was 92.0%. Conclusion: Reasonalbe branch reconstruction strategies could help reduce severe complications of endovascular repair of the aortic arch and achieve better clinical outcomes.