The role of open aortic arch replacement is evolving with technical advances in the endovascular domain. In the modern era, open surgery remains the gold standard for arch intervention given excellent contemporary surgical outcomes using techniques that have been honed since the first successful arch in the 1950s. Delivering these outcomes requires rigorous attention to operative scope and technique, particularly as relates to neurovascular protection of the brain. Anatomic considerations, patient factors, specific aortic disease pathology, durability, and institutional and surgeon experience must be collectively and thoughtfully considered when selecting the best mode of aortic arch intervention, whether it is open surgical or endovascular. Open aortic arch intervention remains favored in the setting of acute aortic syndromes, complex anatomy, heritable thoracic aortic syndromes, and in the young.
Endovascular aortic arch repair has been applied in high-risk patients with highly acceptable early technical and clinical outcomes in large aortic centers. Despite the increasing literature in the field, target-vessel–related outcomes in patients managed with fenestrated and branched thoracic endovascular aortic repair (f/bTEVAR) have not been extensively investigated. Cohorts mainly reporting on the clinical findings of f/bTEVAR suggest high patency rates of up to 100% during mid-term follow-up, whereas re-interventions are mainly attributed to type Ic and IIIc endoleaks, especially in bTEVAR cases. Fenestrations, however, seem to be more prone to usually asymptomatic bridging stent stenoses due to kinking within the initial year of follow-up. Target-vessel–related re-interventions, regardless of the underlying approach, are minimal and usually performed successfully using endovascular means. However, until long-term findings are available in the literature, the fate of the bridging stents, target vessels, and, further patients managed with f/bTEVAR remains unknown. Studies focusing on patient-specific parameters, including the aortic arch and supra-aortic trunk anatomy, material evolution with dedicated bridging stents, which conform to the large target-vessel diameters and hemodynamics of the aortic arch, are scarce. Furthermore, clarifications on the impact of medical treatment on bridging stent performance and long-term outcomes are needed and will hopefully clarify the target-vessel–related outcomes in patients managed with f/bTEVAR.
In the modern era, management of complex disease is often accomplished via a multi-disciplinary approach. Aortic arch pathology is well suited to team-based management given the inherent complexity associated with this anatomic domain. Multidisciplinary aortic teams, allow for the improved care of a challenging subset of conditions. Management of aortic arch disease integrates medical therapy, genetics, open surgical procedures, and endovascular therapies to produce effective, safe, and durable solutions for patients. Given the complexity of disease, no one specialty possesses all the necessary tools for comprehensive care and treatment. Multispecialty collaboration results in improved patient care through the standardization of treatment pathways. Such standardization allows for the establishment of quality benchmarks and promotes a shared understanding amongst all members of the treatment team. Furthermore, this approach can improve interactions amongst specialties and facilitates open communication and idea sharing. There may be significant institutional benefits to the adoption of a multidisciplinary aortic team, such as improved patient follow up, increased patient referral, and improved cost effectiveness of care. In this article we discuss the benefits, challenges and practical application of a multidisciplinary approach to management of the aortic arch, with a specific focus on our own institutional pathway.
Open arch repair remains the gold standard for the treatment of aortic arch pathology. However, complete endovascular aortic arch repair has been performed with excellent outcomes in Europe and in the context of a physician-sponsored investigational device exemption trial within the United States. Because these customized grafts are not readily available, hybrid techniques have evolved to treat aortic arch pathology. Hybrid techniques that combine cervical debranching and the use of the GORE thoracic branched endograft (TBE) have enabled the ability to repair aortic arch pathology with less invasive means using commercially available endografts, with reduced morbidity and mortality. Hybrid approaches using the GORE TBE platform are described herein.
Introduction When autologous vein is not feasible for infrainguinal bypass surgery, biological alternatives are often considered due to their low susceptibility to infection. Between two commonly employed options, the cryopreserved allograft and xenograft, no comparative literature review currently exists. Methods MEDLINE, Embase and Cochrane were searched for eligible studies. Studies reporting clinical outcomes of cryopreserved allografts and/or xenografts were included. The primary outcome was primary patency at 12 months. Secondary outcomes were graft infection (<30 days and >30 days), primary assisted patency, secondary patency, limb salvage, and mortality at 12 months. Clinical outcomes were pooled for comparison using random effects models. Results Thirty-seven cohort studies met the inclusion criteria: twenty-two single-arm cryopreserved allograft studies, fourteen single-arm xenograft studies, and one comparative study. Primary patency at 12 months was comparable between cryopreserved allografts and xenografts (47.1% vs. 65.5%; p = 0.09). Early infection (p = 0.15), late infection (p = 0.79), secondary patency (p = 0.19), limb salvage (p = 0.29) and mortality (p = 0.76) were also not statistically significant. Primary assisted patency at 12 months was significantly higher in the xenograft group (p = 0.048). Statistical heterogeneity was substantial (I2 > 50%) across meta-analyses, except for early graft infection (I2 = 0%). Conclusions Current evidence surrounding cryopreserved allografts and xenografts for infrainguinal bypass surgery suggests potentially similar outcomes. High statistical heterogeneity, heterogeneity in surgery indication and the overall very low quality of evidence limit generalizability, and should therefore not be interpreted as evidence of comparative effectiveness or superiority of either graft type. Well-designed randomized controlled trials are warranted to clarify the comparative evidence of these conduits.
With the advent of endovascular aortic repair (EVAR) in 1991, the role of minimally invasive techniques in aortic surgery not only transformed the toolbox of vascular surgery and its representation as a surgical specialty, but also how vascular trainees are viewed regarding open aortic surgery proficiency. There have been numerous publications that report a decline in open aortic repairs (OAR) during training with a simultaneous increase in endovascular aortic repairs [[1], [2], [3], [4], [5], [6], [7]]. This trend, coupled with increased number of vascular trainees, has fostered the belief that less open aortic surgery is available to current residents, resulting in increased scrutiny over the current training experience. However, recent studies broadened OAR to include operations performed for aortoiliac occlusive disease (AOID) demonstrating that open aortic case volume is stable if not increased amongst current day trainees [8,9]. In this study, we included mesenteric and spine exposures as well as open abdominal aortic trauma in our definition of OAR and found an increase in total open aortic experience (OAE) amongst current day trainees. So while modern day trainees are performing less OAR for abdominal aortic aneurysms (AAA), they are performing more OAR when including other indications such as AOID, spine exposure, open mesenteric exposure, and open abdominal aortic trauma. Although the surgical indications may differ, these procedures involve similar operative exposures and technical skill sets, thereby helping ensure that modern trainees become well trained and proficient in open aortic surgery.
Several different forms of endovascular arch repair are available in practice today. Custom-made devices, represented by fenestrated and branched endografts, have emerged as the first line in endovascular repair and offer broad applicability. Off-the-shelf devices are becoming more common, but emergent repair is still most likely to use in situ fenestration or physician-modified endograft techniques. The current outcomes of these devices are encouraging, even if total endovascular arch repair presents limitations. Careful patient selection, based on anatomical features and previous medical history, and the presence of a well-developed aortic team are the 2 key factors that ensure good outcomes after endovascular repair.
The last two decades have seen a dramatic rise in the use of fenestrated and branched devices designed for endovascular treatment of aortic arch pathology, expanding treatment options for patients at high risk for open repair. This narrative review includes data from peer-reviewed English language articles with >10 patients treated with off-the-shelf and custom-made devices, searched across PubMed, Medline, Embase, Cochrane, and ClinicalTrials.gov. Fenestrated endovascular aortic arch repair has high technical success rates and relatively lower neurological risk, but is more commonly applied to the distal arch, heavily reliant on precise alignment, and requires customization. Branched configurations allow for more proximal and extensive arch reconstruction, and off-the-shelf endografts enable treatment in urgent and emergent settings. Contemporary data have demonstrated improved rates of technical success, decreased operative times, and decreased major adverse events across all stent-graft platforms. However, peri-procedural stroke remains the Achilles’ heel of this technique and a limitation to broad commercial applicability. Mid-term outcomes are encouraging but longer-term durability data are needed. Device heterogeneity as well as differences in clinical outcome definitions make direct comparisons difficult, but in all cases, successful results will depend on appropriate patient selection, aortic arch/landing zone anatomy, careful procedural planning, and ongoing device refinement to maximize outcomes.
The effect of reintervention after elective endovascular abdominal aortic aneurysm repair (EVAR) on survival remains uncertain. Existing studies report inconsistent findings and may be vulnerable to immortal time bias because reintervention occurs at variable times during follow-up, and to confounding bias from time-evolving postoperative factors such as endoleak. We retrospectively analyzed Vascular Quality Initiative registry data for patients undergoing elective EVAR. Reintervention within 2 years after EVAR was modeled as a time-varying exposure, and the outcome was all-cause mortality. The primary analysis used sequential target trial emulation using pooled sequential Cox proportional-hazards models to account for delayed reintervention timing and adjust for baseline and time-varying confounders. A sequential instrumental variable Cox analysis was also performed to address potential unmeasured confounding. In the primary sequential Cox analysis and the IV analysis extension, reintervention was associated with higher all-cause mortality (HR: 1.24 [1.09–1.41], P < .01 and HR: 1.27 [1.07–1.52], P = .01, respectively). In contrast, the naïve Cox model analysis, which is vulnerable to immortality bias, showed no significant association between reintervention and mortality, and the unadjusted time-dependent Cox model, which is vulnerable to unmeasured confounding bias, yielded a stronger adverse association. After accounting for reintervention timing and time-varying confounding, post-EVAR reintervention was associated with modestly higher all-cause mortality. These findings do not establish that reintervention is overused or intrinsically harmful; rather, they suggest that reintervention should not be assumed to universally confer a survival benefit and may be a marker of complicated post-EVAR disease course, device failure, endoleak, higher-risk anatomy, or disease progression. These findings highlight the importance of addressing immortal time bias, time-dependent confounding and unmeasured confounding when evaluating vascular procedures performed after follow-up begins.
The optimal operative strategy for infrarenal abdominal aortic aneurysm (AAA) repair remains one of the most consequential and persistently debated questions in contemporary vascular surgery. Endovascular aortic repair (EVAR) has become the dominant modality for elective repair in the United States and Europe, owing to its compelling perioperative advantages: markedly lower perioperative mortality, fewer intra-operative complications, shorter hospitalization, and faster functional recovery compared with open surgical repair (OSR). Three seminal randomized controlled trials – DREAM, EVAR-1, and OVER – independently confirmed 30-day mortality rates of 0.2-1.8% with EVAR versus 2.3-4.6% with OSR, establishing the early survival benefit of the endovascular approach.Yet this perioperative advantage represents only one dimension of a treatment decision whose implications unfold over years to decades. Long-term follow-up from these trials, together with an expanding body of registry data and meta-analyses, has revealed that EVAR's initial survival benefit attenuates over time, with a directional trend toward higher long-term survival with OSR. Contemporary evidence – including a 2025 meta-analysis of over 26,000 patients – demonstrated that, despite EVAR conferring superior survival in the first eleven months, OSR was associated with improved overall survival from that eleven-month point through fifteen years. EVAR is further burdened by substantially higher reintervention rates, greater risk of late aneurysm-related events, and the constraints of lifelong radiographic surveillance. These trade-offs are substantially modified by patient age, comorbidity burden, frailty, and life expectancy. Contemporary decision-making must therefore integrate patient anatomy, operative risk, age, life expectancy, and surveillance commitment within a shared decision-making framework.
Endovascular abdominal aortic aneurysm (AAA) repair (EVAR) has become the dominant modality for AAA management, accounting for approximately 80% of repairs in the United States, and as such, the burden of post-EVAR surveillance has increased concomitantly. As the risk of late device-related complications following EVAR persists indefinitely, guidelines uniformly highlight the importance of lifelong surveillance, traditionally consisting of computed tomography angiography at 1 month, 6 months, 1 year, and annually thereafter. More recently, however, the optimal post-EVAR surveillance regimen has become a subject of considerable debate, driven in part by an emerging body of evidence suggesting that intensive surveillance protocols may prompt prophylactic reinterventions of uncertain clinical benefit, while simultaneously raising concerns regarding long-term cost-effectiveness, cumulative radiation exposure, and the risk of contrast-induced nephrotoxicity. In light of these concerns, and in the absence of high-quality randomized data, guidelines from major vascular societies have diverged in their recommendations and have attempted to adopt risk-stratified surveillance paradigms. Nonetheless, even in the context of these less intensive regimens, observational studies reveal that surveillance compliance rates remain substantially low. As such, understanding the determinants of noncompliance, its clinical consequences, and strategies to improve adherence represents an increasingly critical priority in the long-term management of patients who have undergone EVAR. In this review, we will describe the existing data informing surveillance practices, the impact of nonadherence to recommended surveillance, and the remaining unanswered questions in contemporary practice.
Acute aortic dissection is a vascular emergency with unpredictable progression and outcomes. Standard imaging modalities, such as computed tomography angiography (CTA), facilitate diagnosis and operative planning but provide limited data on vessel wall mechanics and hemodynamics. Modern imaging and computational models may offer deeper insights into natural history prognostication and risk prediction. This PROSPERO-registered systematic review (CRD42024589703) followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Eligible MEDLINE and Embase studies assessed vessel wall dynamics or hemodynamic modeling in healthy or dissected aortas. The risk of bias was assessed using Risk Of Bias In Non-Randomized Studies – of Interventions; the quality of evidence was evaluated with Grading of Recommendations, Assessment, Development and Evaluation. A total of 36 studies were included, mainly retrospective single-center cohort studies of CT/CTA, magnetic resonance imaging, ultrasound, echocardiography, and digital subtraction angiography. An entry tear size greater than 10 mm on CTA was associated with increased false lumen flow and higher sheer wall stress, causing poor aortic remodeling, as confirmed with 4-dimensional magnetic resonance imaging. Distal entry tears and presence of more entry tears reduced the risk of pulsatile-type dissections, having a long-term protective effect. Helical flow patterns assessed through computational fluid dynamics determining kinetic energy transmission increase proximal false lumen thrombosis with favorable outcomes. Modern imaging and modeling techniques demonstrate potential in predicting disease progression, with the possibility of tailoring aortic dissection management. Because most studies were exploratory in design, they could not establish replicable clinical protocols or measurable parameters. Measurements of false lumen flow, kinetic energy, and entry tear features (size and number) have demonstrated the greatest potential. Further prospective, standardized studies are essential to translate these findings into routine clinical care.
The ascending aorta and aortic root remain challenging areas for endovascular repair. While open surgical repair or replacement remains the gold standard, a proportion of the patients with ascending and/or root pathology are inoperable or at prohibitive surgical risk. Repair using conventional tubular ascending endografts is limited by anatomical constraints, especially inadequate proximal landing zones near the sinotubular junction (STJ), further complicated by the proximity of the coronary ostia. Therefore, endovascular strategies that enable anchoring in the aortic root may be required.To address these limitations, valve-carrying conduit concepts such as Endo-Bentall and Endo-Wheat have been proposed. These configurations integrate a transcatheter aortic valve with an ascending endograft, enabling coronary perfusion through fenestrations, branches, or uncovered segments. Early clinical experience is limited to a few published case reports to date, with heterogeneous techniques and no standardized procedural strategy. Although early technical success and short-term safety appear acceptable, conclusions are constrained by small sample size, selection bias, and limited follow-up.Proof-of-concept investigations, including ex vivo and in vivo animal studies, biomechanical modeling, and bench-top experiments using patient-specific three-dimensional (3D) anatomical models have been reported. These studies suggest stable deployment with preserved coronary perfusion; however, they do not establish clinical efficacy or safety in patients.At present, this approach should be considered an evolving strategy reserved for carefully selected patients with life-threatening aortic pathology where conventional surgery is not an option, pending robust evidence of safety, efficacy, and durability.
Background Centralization of aortic care has been proposed to improve outcomes in abdominal aortic aneurysm (AAA) repair, but its effects may vary according to treatment modality, procedural complexity, and system organization. This scoping review examined the evidence on volume-outcome relationships, failure to rescue (FtR), surgeon and center volume, and integrated models of aortic care. Methods PubMed/MEDLINE was searched from inception to April 29th, 2026. Search terms combined centralization, AAA, hospital volume, surgeon volume, volume–outcome, failure to rescue (FtR), open aortic repair (OSR), endovascular aneurysm repair (EVAR), and ruptured AAA. A narrative synthesis was performed. Results Evidence for an inverse volume–outcome relationship was strongest and most consistent for OSR, in both elective and ruptured AAA. In an analysis of the International Consortium of Vascular Surgery, mortality after intact OSR was 6.0% in the lowest-volume quartile versus 3.6% in the highest, and after ruptured OSR 44.2% versus 30.2%. Lower surgeon volume was also associated with worse OSR outcomes in several studies. Most studies identified approximate center-level thresholds of 10–20 repairs/year. FtR after OSR consistently favored higher-volume centers. By contrast, EVAR showed a more heterogeneous and less reproducible association between center volume and early mortality, particularly in ruptured AAA, although some studies reported lower FtR in higher-volume centers. More limited thoracoabdominal data suggested clearer volume effects in more complex procedures. Conclusions Centralization appears most strongly supported for OSR and emergency AAA care. Better outcomes are likely achieved in services combining open expertise, endovascular capability, structured emergency pathways, and effective peri-operative rescue capacity.
Endovascular aortic arch repair has seen increasing application for the treatment of complex aortic arch pathology in patients with suitable anatomy who are considered high risk for open surgical repair. Ongoing technical advancements have refined stent design, enabling total endovascular incorporation of the supra-aortic vessels. Despite these advances, the procedure remains highly complex and presents unique technical and physiologic challenges related to arch anatomy, device constraints, and cerebral protection. The risk of stroke remains high in several experiences and is the main limitation to widespread utilization in lower-risk groups. A comprehensive understanding of all aspects of the perioperative process is therefore essential to achieve a safe and effective repair. Several key considerations include meticulous patient selection, thoughtful device design, rigorous preoperative planning, precise procedural execution, and diligent postoperative follow-up. Currently available three-vessel arch branch devices remain under investigational protocols, and the outcomes reported thus far largely reflect experience at high-volume aortic centers. This review aims to summarize the current principles and key considerations required to successfully perform a three-vessel endovascular arch repair, with a focus on practical strategies to optimize clinical outcomes and ensure durable results.
Advances in the management of aortic dissection have been driven by rapid innovation in endovascular technology, improved imaging, and multidisciplinary care models. Critical to translating these innovations into broader clinical practices are the US Food and Drug Administration and the Centers for Medicare & Medicaid Services. These organizations' regulatory and reimbursement policies shape device development, patient safety, and access to care. Although the overall mission of the US Food and Drug Administration and Centers for Medicare & Medicaid Services is to provide a structured evaluation and safe introduction of new technologies, as well as evidence-based adoption as standard of care, these frameworks may also contribute to disparities in access to advanced therapies. This review examines the historical evolution of aortic dissection treatment and generation of clinical evidence through the lens of US Food and Drug Administration and Centers for Medicare & Medicaid Services policy and discusses how complementary, yet fragmented, oversight models influence innovation, outcomes, and equity in contemporary aortic dissection care.
Dissection morphology is important when considering landing zones for thoracic endovascular aortic repair. Landing proximally in a healthy aorta, free of dissection and intramural hematoma, is generally recommended. For the most common location of the proximal entry tear near the left subclavian artery, this generally requires landing in zone 2. However, zone 2 landing is associated with higher rates of stroke and need for left subclavian revascularization. Distal landing zone 5 is associated with much higher rates of spinal cord ischemia, without significant benefit over zone 4 or bare metal stent extension so should be avoided, especially for treatment of uncomplicated dissections.
Patient and stakeholder engagement is increasingly emphasized in clinical research, yet practical guidance on how to operationalize engagement in high-acuity, multicenter surgical trials remains limited. We describe the design and early implementation of a structured engagement strategy within the IMPROVE-AD (Improving Outcomes in Vascular Disease-Aortic Dissection) trial. IMPROVE-AD is a pragmatic, multicenter randomized trial comparing optimal medical therapy alone with optimal medical therapy plus thoracic endovascular aortic repair for uncomplicated type B aortic dissection. A formal patient engagement committee, supported by a stakeholder engagement core, was established to integrate patient perspectives into trial design and conduct. Engagement activities included inputs on trial design, recruitment strategies, participant-facing materials, and communication approaches. Observations were derived from the early implementation of these activities. Stakeholder engagement informed several aspects of trial development and implementation. Early engagement contributed to the refinement of trial design elements, including the prioritization of clinical endpoints over surrogate measures. During trial implementation, patient engagement committee input supported the revision of informed consent language, development of public-facing materials, and refinement of recruitment messaging, with an emphasis on clarity, transparency, and clinical equipoise. Access to aggregated screening and enrollment data enabled the identification of potential barriers to recruitment and underrepresentation. These observations are descriptive. A formal evaluation of the impact of engagement on enrollment, retention, or other trial outcomes has not yet been conducted. Structured stakeholder engagement can be incorporated into the design and conduct of a high-acuity, multicenter randomized trial and may inform communication, recruitment, and implementation strategies. Although the full model described here is resource intensive, selected elements may be adaptable across diverse research settings. Further work is needed to evaluate the impact of engagement and to identify scalable approaches.
