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.
