The Present and Future of Zone 0 Endovascular Arch Reconstruction

Thoracic aortic pathology involving the aortic arch is most commonly treated with open total arch replacement. However, open surgery is still associated with significant risk of mortality and morbidity, particularly in the elderly, patients with high-risk comorbidities, and those with previous cardiac surgery. Multiple endovascular approaches to enable zone 0 arch reconstruction have been developed, including custom-made, physician-modified, and off-the-shelf fenestrated/branched endografts. The initial experiences of this approach have been plagued by high incidence of stroke; although improvements have been made over the past decade, it remains suboptimal. Several factors contribute to this stagnation, including limited descriptive studies with small sample sizes, heterogeneous patient populations, varied techniques, and lack of data granularity and standardization. These limitations reduce the ability to analyze factors that could improve patient selection, device design, and procedural techniques. In addition, consistent follow-ups have not been reported, and the long-term outcome of these interventions are unknown. To address these issues, a randomized controlled trial of open versus endovascular arch repair or multicenter registry with standardized data reporting, follow-up protocol, and sufficient sample size would be needed. High-quality data will help identify patient clinical or anatomical features as well as procedural factors that can improve outcomes.