Background:Diseases of the aortic arch represent some of the most complex conditions in cardiovascular medicine due to the segment's unique anatomy and its involvement in cerebral perfusion. Although isolated aortic arch pathology is relatively uncommon, the arch is frequently affected as part of more extensive thoracic aortic disease, including aneurysms, acute and chronic aortic dissections as well as penetrating aortic ulcers. The close relationship of the arch to the supra-aortic vessels and adjacent mediastinal structures contributes to the significant morbidity and mortality associated with these conditions and complicates therapeutic decision-making. Methods:This review provides a comprehensive overview of the spectrum of diseases involving the aortic arch and summarizes contemporary treatment strategies. Particular emphasis is placed on anatomical considerations and classification systems, including the Ishimaru zones and variations in aortic arch morphology, which are essential for standardized reporting and procedural planning. Key pathological entities discussed include aortic arch aneurysms, acute and chronic dissections involving the arch, and residual aortic dissection following repair of type A dissection. Results:Current treatment options encompass guideline-directed medical therapy, open surgical reconstruction, and evolving endovascular approaches. Open aortic arch replacement, often performed with hypothermic circulatory arrest and selective antegrade cerebral perfusion, remains the reference standard for patients with acceptable operative risk due to its durability and favorable long-term outcomes. In parallel, technological advances have enabled the development of branched thoracic endovascular aortic repair (B-TEVAR) and fenestrated thoracic endovascular aortic repair (F-TEVAR) devices, including both custom-made and off-the-shelf solutions, expanding treatment possibilities for patients at high surgical risk. Conclusions:Careful patient selection based on anatomical characteristics, disease acuity, comorbidities, and institutional expertise is essential to optimize outcomes. Contemporary management of aortic arch disease therefore requires an individualized, multidisciplinary approach integrating both open and endovascular strategies.
This review outlines the history of aortic arch surgery and examines classifications of hypothermia and mechanisms of perioperative neurological injuries. Risk factors for these neurological insults are explored, as well as cerebral monitoring systems available to mitigate such injuries. Furthermore, a comparative literature analysis evaluates outcomes among deep hypothermic circulatory arrest, retrograde cerebral perfusion, and antegrade cerebral perfusion. Finally, technical considerations for cerebral perfusion delivery and contemporary trends in temperature management are discussed.
Background:Acute type A aortic dissection (ATAAD) is a surgical emergency with time-dependent mortality. Surgical outcomes in high-volume centers are excellent, yet population-level outcomes remain catastrophic. This gap reflects a systems failure in recognition, diagnosis, and coordination rather than surgical inadequacy, and no formal time-based pathway currently governs care from emergency presentation to surgery. Methods:Current epidemiology, international guidelines, registry evidence, and national audit data were synthesized, together with the structure of established time-critical pathways in ST-elevation myocardial infarction, stroke, major trauma, and sepsis, and multidisciplinary and patient-and-public input, to derive a temporal framework for ATAAD. The framework is advanced as a hypothesis for formal international consensus validation rather than an empirically validated standard. Results:The proposed framework, the aortic window, is a phased pathway from emergency-department (ED) arrival to first surgical incision, structured as RACE (four acute phases: REACH, ALERT, CONVEY, ESCALATE) and RESTORE (recovery and lifelong surveillance), and operationalized through a named activation protocol. ED-to-incision time is the principal whole-system endpoint, chosen because it captures pre-diagnosis delay that diagnosis-anchored metrics exclude. Process and outcome measures are defined at case level with scheduled network review, aligned to established national audit registries. Implementation is staged and incorporates an education and run-in period before performance assessment. Conclusions:The aortic window reframes ATAAD as a system-level, time-critical emergency amenable to the organizational solutions that improved outcomes in other time-dependent conditions. The proposed targets require prospective evaluation but provide a structured, measurable basis for coordinated pathway improvement.
The management of complex aortic disease has evolved toward a "lifetime management" strategy, where the initial surgical arch repair critically influences the feasibility of future staged interventions. While the left subclavian artery has received significant attention, the strategic role of the innominate artery (IA) as a primary endovascular gateway remains underappreciated. This paper explores how IA reimplantation geometry determines the success of subsequent endovascular procedures. We analyzed the technical requirements for optimal antegrade endovascular access during complex downstream repairs, such as branched and fenestrated endovascular aortic repair (B-FEVAR). Two surgical strategies aimed at optimizing supra-aortic vessel alignment were evaluated: the "arch vessels' switch" technique using a standard trifurcated graft, and the use of the novel T-NEXT hybrid prosthesis (Terumo Aortic, Vascutek Ltd., Renfrewshire, UK). In currently available frozen elephant trunk (FET) and hybrid arch grafts, the longitudinal arrangement of supra-aortic branches often results in sequential vessel reimplantation patterns that may create acute angulations between the IA and the ascending aorta. Such configurations can impair guidewire and catheter maneuverability, reducing effective transmission of torque and forward force during antegrade navigation toward the descending thoracic and thoracoabdominal aorta. The "arch vessels' switch" technique, in which the IA is reimplanted onto the distal (3rd) branch of a standard trifurcated graft, improves coaxial alignment and creates a smoother, more anteriorly directed trajectory for catheters and delivery systems intended for downstream aortic interventions. Similarly, the T-NEXT hybrid prosthesis (Terumo Aortic, Vascutek Ltd.) combines preservation of a longer native ascending aortic segment, potentially facilitating future root or ascending aortic reinterventions with a dedicated transverse 10-mm IA branch that provides a stable and pre-aligned access route. This optimized geometry minimizes abrupt directional changes at the anastomotic level, facilitates device advancement, and enhances support for guidewires, sheaths, and endovascular adjuncts. IA reimplantation should be conceptualized as a strategic maneuver rather than a purely reconstructive step. A multidisciplinary "aortic team" approach is essential to design arch reconstructions that facilitate bidirectional endovascular navigation. By optimizing IA take-off geometry, surgeons can prevent "dead-end" anatomies and ensure that the primary arch repair serves as a durable platform for the patient's entire therapeutic journey.
Frozen elephant trunk (FET) repair has expanded the treatment of complex aortic arch pathology but continues to rely on hypothermic circulatory arrest (HCA), which remains a major physiological limitation of the procedure. In this Keynote, we describe our current normothermic FET strategy, designed to perform arch reconstruction under continuous cerebral and systemic perfusion, through the integration of open and endovascular techniques. Retrograde stent-graft deployment and balloon occlusion within the prosthesis allow controlled distal aortic clamping while maintaining uninterrupted systemic circulation. In our initial experience, the technique was technically feasible and associated with acceptable perioperative hemodynamic and metabolic profiles; however, given the limited clinical experience, these findings should be interpreted as preliminary and require further evaluation. Beyond its technical aspects, this approach reflects a conceptual shift in arch surgery from mitigating the consequences of circulatory arrest to pursuing strategies aimed at avoiding it. In selected patients, normothermic FET may represent a physiologically oriented option within the ongoing evolution of contemporary aortic arch repair.
Background:Endovascular repair of aortic arch pathology is an evolving treatment option for selected patients, particularly those at high or prohibitive risk for conventional open arch replacement. However, the complex three-dimensional anatomy of the aortic arch, high pulsatile flow, proximity of the supra-aortic vessels, and the need for durable proximal and distal sealing make these procedures technically demanding. Careful patient selection, high-quality imaging, and systematic preoperative planning are therefore essential determinants of procedural success. Methods:This article presents a structured approach to preoperative planning for endovascular aortic arch repair. The planning process includes confirmation of guideline-based indications for intervention, operative risk assessment, selection between open, hybrid, and total endovascular strategies, detailed computed tomography angiography analysis, three-dimensional reconstruction, centerline-based measurements, assessment of landing zones, supra-aortic vessels, access vessels, cerebral collateral circulation, and device-specific anatomical requirements. Results:Computed tomography angiography remains the principal imaging modality for procedural planning and should include thin-slice acquisition, appropriate contrast opacification, electrocardiogram (ECG)-gated assessment of the ascending aorta and arch, and scan coverage extending from the circle of Willis to the femoral arteries. Systematic image analysis should begin with axial source images before three-dimensional reconstruction, in order to identify thrombus, calcification, shaggy aorta, dissection, intramural hematoma, anatomical variants, and other features relevant to device implantation. Centerline and curved multiplanar reconstruction allow accurate measurements of vessel diameter, length, curvature, landing zones, and supra-aortic vessel orientation. These data guide the selection of debranching, scalloped, fenestrated, or branched endovascular strategies. Conclusions:Successful endovascular aortic arch repair depends on meticulous preoperative planning, multidisciplinary decision-making, and strict anatomical feasibility assessment. Because current arch endovascular technologies remain anatomically restrictive and device-specific, they should be applied only in carefully selected patients after comprehensive imaging analysis and comparison with available surgical alternatives.
Background:Cerebral protection is a key determinant of perioperative outcomes in aortic arch surgery. Despite significant advances, optimal strategies regarding temperature, perfusion modality, and cannulation site remain controversial, with heterogeneous evidence and lack of standardized protocols. Methods:This narrative review summarizes experimental and clinical evidence from the last 15 years, focusing on the main determinants of cerebral protection: cerebral blood flow (CBF), autoregulation, perfusion pressure, temperature management, cannulation strategies, and antegrade (ACP) versus retrograde cerebral perfusion (RCP). Results:Available evidence consistently shows that any form of cerebral perfusion is superior to no perfusion during circulatory arrest (CA). Selective antegrade cerebral perfusion (SACP) has progressively emerged as the most widely adopted strategy worldwide, supported by its more physiological flow pattern and encouraging clinical outcomes. Axillary artery cannulation is currently the preferred approach and is associated with a lower stroke risk compared to femoral access, although femoral cannulation remains a valid alternative in unstable patients requiring rapid cardiopulmonary bypass (CPB) initiation. Comparative studies between ACP and RCP demonstrate no clear superiority in terms of mortality or permanent neurological dysfunction (PND), particularly for short CA times. However, SACP may reduce temporary neurological deficits (TNDs). A global shift towards moderate-to-mild hypothermia combined with cerebral perfusion has been observed, with favorable outcomes. Nonetheless, substantial variability persists in perfusion parameters, including flow, pressure, and the choice between unilateral and bilateral cerebral perfusion. Conclusions:Contemporary practice is moving toward strategies that better replicate physiological cerebral perfusion, favoring antegrade flow with moderate hypothermia. However, the lack of high-quality randomized evidence and persistent heterogeneity limit definitive recommendations, highlighting the need for standardized protocols and individualized approaches.
Treatment of aortic arch pathology is one of the most challenging areas in cardiovascular surgery due to the complex anatomy and proximity to critical cerebral vessels. Open aortic arch replacement with cardiopulmonary bypass and deep hypothermic circulatory arrest remains the gold standard but can be associated with significant perioperative morbidity and mortality, particularly in elderly and comorbid patients. Over the past two decades, thoracic endovascular aortic repair (TEVAR) has become the gold standard for most descending aortic pathologies. As a result, TEVAR use has expanded into the aortic arch, facilitated by hybrid approaches that combine supra-aortic vessel debranching with endovascular stent-grafting. Following this approach, TEVAR, in combination with the use of chimney and snorkel grafts, was developed in an attempt to treat the aortic arch with a complete endovascular approach. However, these techniques have been associated with complications such as stent-graft occlusion, collapse, endoleaks, and strokes. Further developments have led to in situ laser fenestrations, and branched and fenestrated endografts, thus enabling total endovascular reconstruction. Contemporary series demonstrate high technical success with acceptable early outcomes in selected high-risk patients. In addition, an increasing experience has been reported with hybrid approaches to the aortic arch, often involving a zone 2 arch replacement followed by completion TEVAR when indicated. While hybrid and endovascular strategies expand the therapeutic armamentarium, careful patient selection, meticulous procedural planning, and preservation of cerebral and spinal perfusion are paramount to minimizing neurological complications. Emerging device technologies, including off-the-shelf branched systems and modular delivery platforms, along with advanced imaging and computational planning, continue to improve procedural safety and feasibility. Lastly, the impact of stiff stent-grafts on the cardiovascular system is largely unknown but raises concerns, as it diminishes the Windkessel function of the proximal aorta. This appears to lead to increased left ventricular afterload, new-onset hypertension, adverse cardiac remodeling, and increased strain in adjacent aortic segments. This keynote lecture reviews the evolution of endovascular technology for aortic arch repair from innovation to integration, discusses current treatment strategies, and highlights future directions that may further optimize endovascular therapy in modern aortic practice.
Frozen elephant trunk (FET) is an established treatment modality for complex aortic arch and proximal descending aortic pathologies. While patients with limited life expectancy are more frequently considered for endovascular treatment options, the FET remains a sustainable platform, especially for younger post-dissection and heritable thoracic aortic disease (HTAD) patients. These patients frequently have undergone previous transsternal operations. A substantial portion require concomitant aortic root or other cardiac procedures. In this manuscript we describe our technique of redo valve sparing aortic root replacement (VSARR) and total aortic arch repair with FET implantation. Our technique combines four main technical aspects: (I) central arterial cannulation is our first option with axillary access being a secondary alternative. Femoral cannulation is only used in bail-out situations or in combination with upper body arterial access. (II) We prefer to revascularize the left subclavian artery (LSA) within the chest during the same procedure. Many alternative options exist for specific anatomical situations. Ideally, the LSA revascularization technique should not add any hypothermic circulatory arrest (HCA) time to the procedure. (III) We liberally address concomitant cardiac pathologies during the same procedure. To avoid long cardiac ischemia times in these complex cases, we employ non-cardioplegic myocardial perfusion during aortic arch repairs where ischemia times of >120 min are anticipated. (IV) During aortic arch preparation we use temporary "flush" retrograde cerebral perfusion (RCP) to reduce the risk of embolization to the supraaortic arteries. After aortic arch preparation bilateral or trilateral selective antegrade cerebral perfusion (SACP) is routinely initiated. The technique allows complex combined cardiac and aortic arch operations to be performed in a standardized and controlled surgical environment. FET implantation will remain an important open surgical tool in the armamentarium of complex aortic arch repair. Creating durable surgical results and minimizing surgical risks have to be the primary goals regarding surgical management.
Background:Severe tricuspid regurgitation (TR) is associated with high morbidity and mortality. Tricuspid transcatheter edge-to-edge repair (T-TEER) improves TR severity and symptoms, yet survival benefit remains uncertain. This meta-analysis aims to evaluate 1-year outcomes after T-TEER and explore clinical and echocardiographic correlates of prognosis. Methods:A systematic search of PubMed/MEDLINE, Web of Science, and Scopus was conducted through June 2025. Studies enrolling ≥100 patients undergoing T-TEER and reporting 1-year outcomes were included. Primary endpoints were 1-year all-cause mortality, heart failure (HF) hospitalization, and persistence of New York Heart Association (NYHA) class III-IV. Early residual TR (≥3+), assessed at the earliest post-procedural time point within 30 days, was a secondary endpoint. Results:Ten studies, including 4,134 patients, were analyzed. At 1-year, pooled all-cause mortality was 14.0% [95% confidence interval (CI): 9.6-18.5%], HF hospitalization 16.9% (95% CI: 8.7-25.1%), and 30.9% of patients remained in NYHA class III-IV (95% CI: 22.1-39.7%). Early residual TR ≥3+ occurred in 19.1%. In meta-regression analysis, more contemporary recruitment periods were associated with lower 1-year mortality, whereas single-center design was associated with higher early residual TR ≥3+. Exploratory aggregate-level analyses suggested potential associations between comorbidity burden and mortality, right-sided dysfunction and HF hospitalization, and left-sided disease and persistent functional limitation. Conclusions:T-TEER effectively reduces TR and improves functional status; however, 1-year mortality and HF hospitalization remain substantial. More contemporary recruitment periods were associated with lower 1-year all-cause mortality, suggesting improved outcomes over time. Systemic comorbidity burden, right-sided disease, and concomitant left-sided disease may contribute to residual risk after T-TEER; however, these associations should be considered hypothesis-generating and require validation in individual patient-level datasets. Meta-analysis Registration:CRD420251155094.
