Introduction The use of retrograde branches during endovascular aortic arch repair in chronic dissections has been associated with endograft lumen compression in the distal arch true lumen. This results in a functional pseudocoarctation, which carries a risk of cardiac failure. Technique This exemplar case presents a patient treated with a three-branch arch endograft for an anastomotic false aneurysm and a residual chronic arch dissection extending to the supra-aortic trunks. To overcome device compression, a kissing angioplasty of the endograft and the left common carotid artery branch was performed after achieving wire access to the left subclavian artery. This manoeuvre successfully disrupted the distal arch lamella while securing the left common carotid artery bridging stent and maintaining access to the left subclavian artery. Discussion This technique is now routinely performed in all patients presenting with chronic aortic dissections. In the authors’ limited recent experience with short-term follow up, no instances of cardiac failure secondary to endograft lumen narrowing have been observed since implementing this manoeuvre. It appears to be a feasible and effective method for overcoming endograft lumen compression and its associated complications.

Acute and chronic lower limb ischemia remains a frequent and major therapeutic challenge, particularly in patients with complex and multisegmental arterial disease. Hybrid revascularization strategies, combining open surgery and endovascular techniques, allow optimization of revascularization while limiting procedural morbidity in an often high-risk patient. In acute limb ischemia, the combination of surgical radio-guided thrombectomy or embolectomy with percutaneous transluminal angioplasty and/or stenting enables simultaneous treatment of thrombotic occlusion and underlying arterial lesions. In chronic limb-threatening ischemia, hybrid approaches combine targeted surgical procedures (endarterectomy, short bypass) with proximal or distal endovascular interventions, tailored to multilevel disease, offering often the best treatment for each anatomical level disease. Reported outcomes demonstrate high limb salvage rates, reduced perioperative complications, and shorter hospital stays. In chronic cases the endarterectomy of the femoral bifurcation (gold standard for this anatomical level) optimizes the run-on or the run-off of the hybrid revascularization. Successful implementation relies on careful patient selection (clinic, preoperative angio scan, strategy and sizing), advanced technical expertise (vascular and endovascular techniques), availability of a large endovascular arsenal materials and access to a hybrid operating environment or a fully equipped operating room (C-arm and mobile operating table, echography). This presentation highlights the current role and future perspectives of hybrid surgery in the management of lower limb chronic and acute ischemia.

OBJECTIVE:To compare postdeployment geometry, early clinical outcomes, and late durability of expanded polytetrafluoroethylene (ePTFE) vs polyethylene terephthalate (PET) bridging stents (BSs) used for brachiocephalic trunk (BCT) incorporation during arch branched endovascular aortic repair (A-BEVAR). METHODS:A retrospective single-center analysis was conducted of patients undergoing A-BEVAR with a triple branch and antegrade BCT incorporation between 2018 and 2025. Patients were stratified according to BCT BS material (ePTFE vs PET). Postoperative computed tomography imaging was used to assess stent length behavior, diameter mismatch, angulation, and tortuosity. Early outcomes included technical success and 30-day complications. Late outcomes included BCT-related reinterventions and all-cause mortality. RESULTS:Seventy-nine patients were included (36 ePTFE, 43 PET). PET BSs demonstrated significantly greater foreshortening and changes in angulation compared with ePTFE devices (all P < .05). Technical success exceeded 94% and early clinical outcomes, including stroke, reintervention, and 30-day mortality, were comparable between groups. During follow-up, all-cause mortality did not differ between graft types (log-rank P = .639). Freedom from BCT-related reintervention was significantly higher in the ePTFE group (log-rank P = .039). CONCLUSIONS:Although early outcomes were similar, ePTFE BSs demonstrated more favorable postdeployment geometry and improved freedom from late BCT-related reintervention compared with PET stents. These findings suggest that graft material may influence long-term durability after A-BEVAR.

OBJECTIVE:Routine post-operative admission to the intensive care unit (ICU) is often advocated following fenestrated and/or branched endovascular aortic repair (FBEVAR) of complex abdominal aortic aneurysms (cAAAs) and thoraco-abdominal aortic aneurysms (TAAAs). Given limited ICU resources, identifying pre- and intra-operative predictors of major adverse events (MAE) is crucial for optimal resource allocation. METHODS:Consecutive elective FBEVAR procedures performed between December 2012 and May 2020 were analysed retrospectively. Patients were divided into three groups based on aneurysm extent as cAAA, type 4 TAAA (TAAA4), and types 1 - 3 TAAA (TAAA1-3). MAEs were defined according to current Society for Vascular Surgery reporting standards. The primary endpoint was thirty day MAEs. Candidate pre- and intra-operative predictors were entered into a least absolute shrinkage and selection operator (LASSO) penalised logistic regression, followed by an unpenalised post-LASSO refit to report odds ratios (ORs). RESULTS:Four hundred and thirty-nine patients (129 cAAAs, 193 TAAA4, and 117 TAAA1-3) with 1 694 target arteries were included; 86.3% had four or more vessels incorporated. Primary technical success was 95.9% and the mean surgical time was 185 ± 68 minutes. MAEs occurred in 9.6% (n = 43), including a 3.6% mortality rate (n = 16). Most MAEs (75.0%) occurred within forty-eight hours. Grade 3 spinal cord ischaemia occurred in 1.6%, which was higher in patients with TAAA1-3 (4.3%; p = .023). The thirty day re-intervention rate was 8.2% (2.7% stent graft related; 3.4% access related). In the post-LASSO refit, women (OR 3.59, 95% confidence interval [CI] 1.07 - 10.8; p = .030), unplanned additional procedures (OR 2.62, 95% CI 1.18 - 5.75; p = .020), total fluoroscopy time (OR 1.67, 95% CI 1.20 - 2.29; p = .002), and norepinephrine use (OR 3.23, 95% CI 1.46 - 7.14; p = .003) were independently associated with MAEs. Model performance showed an area under the receiver operating characteristic curve of 0.78 (95% CI 0.69 - 0.85). CONCLUSION:This study suggests that women undergoing complex operations with unplanned additional procedures or extended total fluoroscopy time would benefit the most from close monitoring to detect MAEs in the immediate aftermath of FBEVAR. In contrast, men without these features might be candidates for standard monitoring.

OBJECTIVE:To compare the midterm outcomes after fenestrated and branched endovascular repair in male and female patients and to assess factors associated with sex-related outcomes. METHODS:Data from 423 patients who underwent fenestrated and/or branched endovascular repair between 2016 and 2021 in two aortic centers for degenerative aneurysm or postdissection involving the thoracoabdominal aorta and pararenal aorta were retrospectively collected. The cohort was dichotomized according to sex, and sex-related outcomes after fenestrated and/or branched endovascular repair were assessed. Cases managed for type I to III thoracoabdominal aortic aneurysms were analyzed separately from type IV and pararenal aneurysms. The implanted devices were custom-made devices (COOK Medical) or off-the-shelf t-branch (COOK Medical). RESULTS:Among 423 patients included, 73 (17.3%) were female. Female patients had more extensive disease, with 50.7% treated for type II/III thoracoabdominal aneurysms compared with 23.1% in male patients; consequently, female patients were more frequently treated with branched grafts. The estimated freedom from aorta-related mortality at 12 and 36 months was 99.1% and 93.4% in females and 98.6% and 95.7% in males, respectively (log rank P = .401). In multivariate analysis, female sex remained not associated with aortic-related mortality (hazard ratio [HR]: 0.62, 95% confidence interval [CI]: 0.20-1.91; P = .41). Freedom from aortic-related intervention at 12 and 36 months was 95.7% and 66.3% in females and 92.9% and 72.6% in males, respectively (log rank P = .588). Sex was not significantly associated with target vessel instability after multivariate analysis (HR: 1.28, 95% CI: 0.63-2.57; P = .497). Major adverse events (MAEs) were more frequent among female patients (9.5% vs 2.6%; P = .004) with a higher rate of myocardial infarction, acute renal failure with dialysis, and spinal cord ischemia. In multivariate logistic regression, female sex remained independently associated with a higher risk of MAEs (odds ratio: 0.222, 95% CI: 0.066-0.752; P = .015). In adjusted analysis, no independent association between sex and either device- or procedure-related complications was observed. The extent of aneurysm was not significantly associated with MAEs (HR: 1.137, 95% CI: 0.359-3.598; P = .828). CONCLUSIONS:Female sex was independently associated with a higher risk of MAEs, whereas aneurysm-related mortality and rates of aortic reintervention were comparable between males and females at a midterm follow-up after fenestrated and branched endovascular aortic repair.

OBJECTIVE:To evaluate morphological and clinical outcomes after false lumen occluder (FLO) implantation for postdissection thoracoabdominal aortic aneurysm and to investigate the impact of adjunctive false lumen embolization on aortic remodeling. METHODS:A retrospective single-center study included 71 patients (median age, 64 years; interquartile range, 58-70 years; 77.5% male) with chronic type B aortic dissection treated between June 2018 and December 2024 with third-generation FLO implantation during thoracic endovascular aortic repair (TEVAR) or fenestrated/branched repair. Aortic, true lumen (TL), and false lumen (FL) volumes were quantified using three-dimensional reconstructions on Aquarius software. FLO remodeling was defined as compression of the occluder with a crescent shape on follow-up imaging. Aortic remodeling (FL regression) was defined as a ≥10% reduction in FL volume, stability as ±10% change, and enlargement as >10% increase compared with baseline. Associations between clinical, anatomical, and procedural variables and remodeling outcomes were analyzed using nonparametric and mixed effects models. RESULTS:Across 268 imaging examinations, total aortic and FL volumes decreased significantly over time, whereas the TL volume expanded (all P < .001). The median total aortic volume declined from 796 cm3 at 1 month to 706 cm3 at 4 years, and the FL volume decreased from 501 cm3 to 296 cm3, whereas TL volume increased from 287.5 cm3 to 358 cm3. Median follow-up was 13.3 months (interquartile range, 5.6-36.5 months). Aortic remodeling occurred in 83.1% of patients, FL stability in 12.7%, and enlargement in 4.2%. Regression was more frequent in younger patients (P = .048) and those with smaller baseline diameters and volumes (P = .043 and P = .034). Adjunctive embolization was strongly associated with TL expansion (χ2 = 5.8; P = .016) and FLO remodeling (χ2 = 5.2; P = .022), and showed a trend toward increased aortic remodeling (χ2 = 4.8; P = .056) without added mortality or morbidity. No cases of spinal cord ischemia occurred. FLO size (≥40 mm vs <40 mm) and position (thoracic, diaphragmatic, or abdominal) did not influence outcomes. FLO remodeling was strongly correlated with concurrent FL reduction (χ2 = 20.8; P < .001) and may represent a radiologic marker of procedural success. CONCLUSIONS:FLO implantation provided durable aortic remodeling in chronic type B aortic dissection, and adjunctive embolization enhanced remodeling efficacy by eliminating residual perfusion without increasing risk. The absence of spinal cord ischemia and the identification of FLO remodeling as a surrogate of success highlight the value of this combined, low-risk strategy for long-term aortic stability.

Over the last two decades, there have been dramatic advancements in fenestrated and branched technology for endovascular repair of the thoracoabdominal aorta. The global development of these minimally invasive techniques decreased their short-term morbidity and mortality, compared to open aortic replacement. However, the need for secondary reinterventions remains frequent, although they are typically percutaneous. Continual device modifications, improved implantation techniques, and greater understanding of the endovascular tenets constantly improve rates of long-term success. Challenges exist in endovascular repair of post-dissection thoracoabdominal aortic aneurysms (PD TAAAs) with narrow paravisceral true lumen, and our institutional experience evolved from fenestrated to inner/outer branched technology to mitigate the long-term risk of target vessel instability. Refined strategies in bridging stent grafts, particularly in target vessels off the false lumen, lowered target vessel reintervention rates. Prophylactic and therapeutic management of the false lumen is essential to prevent continued aortic degeneration and to mitigate the risk of spinal cord ischemia. Over the next decade, endovascular management of PD TAAAs will continue to evolve, further improving long-term outcomes.

OBJECTIVE:Retrograde branches have been used during complex endovascular aortic repair, but their outcomes have not been reported. This study evaluated the retrograde branch performance for renovisceral and other aortic side branches at 30 days and during follow up. METHODS:A multicentre retrospective study (Universität Regensburg; Protocol: 24-3786-101) was conducted according to Strengthening the Reporting of Observational Studies in Epidemiology guidelines among centres in Europe, the USA, and New Zealand encompassing patients managed from 1 January 2013 to 31 January 2025. Consecutive patients with thoraco-abdominal and complex abdominal aortic pathologies managed with patient specific company manufactured devices (CMDs) or physician modified endografts (PMEGs) incorporating at least one retrograde branch were included. Technical success, 30 day primary patency, target vessel instability, and re-intervention were analysed. Follow up outcomes were assessed (Kaplan-Meier estimates). RESULTS:A total of 146 patients were included (72.6% men; age 70.6 ± 2.0 years); 25.3% were managed urgently. Twenty one (14.4%) aneurysms were juxtarenal, 14 (9.6%) were pararenal, and 111 (76.0%) were thoraco-abdominal (38 [26.0%] chronic dissections). One hundred and nine (74.7%) CMDs and 37 PMEGs were implanted, with 575 target vessels; 176 were targeted through a retrograde branch (nine superior mesenteric arteries, 25 coeliac trunks, 118 renal arteries, and 24 other side branches). One hundred (56.8%) of these vessels were bridged with balloon expandable, 46 (26.1%) with self expanding, and 27 (18.5%) with a combination of both covered stent types. The retrograde branch associated technical success was 97.7%. The 30 day primary patency was 97.7% and the re-intervention rate was 1.7%. The mean follow up duration was 21.5 ± 4.8 months. The primary patency and freedom from instability were 81.0 ± 5.7% and 78.2 ± 5.7% at 48 months. The freedom from re-intervention was 92.9 ± 2.5% at 12 months, without further re-intervention during follow up. There was no difference between 6 mm and 8 mm branches or between CMDs and. PMEGs. CONCLUSION:Retrograde branches for bridging well selected renovisceral arteries and other aortic side branches were related to high technical success and good patency during midterm follow up.

Over the last two decades, there have been dramatic advancements in fenestrated and branched technology for endovascular repair of the thoracoabdominal aorta. The global development of these minimally invasive techniques decreased their short-term morbidity and mortality, compared to open aortic replacement. However, the need for secondary reinterventions remains frequent, although they are typically percutaneous. Continual device modifications, improved implantation techniques, and greater understanding of the endovascular tenets constantly improve rates of long-term success. Challenges exist in endovascular repair of post-dissection thoracoabdominal aortic aneurysms (PD TAAAs) with narrow paravisceral true lumen, and our institutional experience evolved from fenestrated to inner/outer branched technology to mitigate the long-term risk of target vessel instability. Refined strategies in bridging stent grafts, particularly in target vessels off the false lumen, lowered target vessel reintervention rates. Prophylactic and therapeutic management of the false lumen is essential to prevent continued aortic degeneration and to mitigate the risk of spinal cord ischemia. Over the next decade, endovascular management of PD TAAAs will continue to evolve, further improving long-term outcomes.

Endovascular management of complex proximal ascending aorta, aortic valve, and aortic root pathology represents the final frontier of aortic intervention. The Endo-Wheat and Endo-Bentall procedures aim to replicate the principle of surgical replacement by combining an endograft, a transcatheter valve, and a strategy for maintaining coronary perfusion with or without coronary revascularization. A new anatomical definition of zone 0 has been recommended by several authors to facilitate standardized reporting in the proximal ascending aorta and aortic root. Multiple feasibility studies have demonstrated variable anatomical suitability for Endo-Wheat and Endo-Bentall procedures depending on the aortic pathology studied, with key limitations including coronary size, height, and angulation, as well as a dynamic, short, and nonuniform proximal landing zone. Early preclinical studies, first-in-human experiences, and case series have demonstrated clinical feasibility using different combinations of endograft and transcatheter aortic valve systems, with various arterial accesses, with or without extracorporeal cardiopulmonary bypass support. However, the collective sample size remains very small, with carefully selected cases, heterogeneous techniques, and short-term follow-up. Ultimately, an optimal Endo-Wheat or Endo-Bentall device will require a dedicated design addressing considerations involving the proximal and distal landing zones, aortic valve, coronary perfusion, mechanism of deployment, access, and device durability. Ongoing innovations and clinical evaluations in these areas will ultimately determine the general applicability and reproducibility of this technology in patients with proximal thoracic aortic disease.

Cardiac reoperation after an extra-anatomic aortic bypass graft entails considerable risk due to the proximity of the graft to the sternum. In the case discussed here, a woman with 2 prior sternotomies and a retrosternal aortic bypass graft for a history of aortic coarctation presented with advanced dilated cardiomyopathy requiring heart transplantation. The patient was managed through a novel 3-stage hybrid strategy. In the first stage, a catheter-based approach was used to stent the coarcted aorta. Subsequently, the extra-anatomic graft was endovascularly excluded and, finally, the patient underwent reoperation for heart transplantation. The use of interdisciplinary collaboration for coordinated staging and shared decision-making, as in this case, allows for innovative solutions and improved outcomes in complex surgical needs.

Innovation in the treatment of ascending aorta and arch pathology with novel catheter-based and hybrid procedures has driven the need for a strategy to guide their safe application. The ARCH-ARC (Aortic Arch Academic Research Consortium) was established to pragmatically develop consistent clinical end points and to standardize definitions for use in studies of these new technologies. The ARCH-ARC team, consisting of independent international specialists in cardiac surgery, vascular surgery, vascular medicine, cardiology, neurology, radiology, and clinical trials, along with US Food and Drug Administration, industry, and contract research organization representatives, held virtual meetings from 2021 to 2025. Consensus was used to identify appropriate clinical end points and to standardize definitions of end points for endovascular, hybrid, and open surgical procedures in clinical trials in the ascending aorta and arch. Drawing on previous ARC work in cardiac, neurological, renal, and bleeding end points, the ARCH-ARC focused on definitions and end points related to aortic arch-specific anatomy, pathology, and procedures and clinical, device, and imaging. The adoption of the ARCH-ARC consensus definitions and end points will provide a template for consistent adjudication and event reporting and facilitate comparisons of clinical research studies involving devices for ascending aorta and arch pathology.

BACKGROUND:Redo open arch repair is challenging; arch branched endovascular aortic repair (a-BEVAR) offers a less invasive alternative. However, direct comparisons are lacking. The aim of this study was to compare the outcomes of open arch repair versus a-BEVAR in patients with residual aortic dissection after ascending aorta replacement for acute Stanford type A aortic dissection. METHODS:This multicentre retrospective study included patients treated for residual dissection after type A aortic dissection in ten high-volume centres from January 2018 to May 2024. Propensity score matching (1 : 1) was used to adjust for baseline differences. Primary endpoints included 30-day mortality and stroke rates, and secondary endpoints included acute kidney injury, spinal cord ischaemia, reintervention, aortic-related mortality, and hospital length of stay. RESULTS:A total of 183 patients were included: 89 (48.6%) underwent open arch repair and 94 (51.4%) underwent a-BEVAR. After propensity score matching, there were 57 patients in each group. The 30-day mortality rate was 3.5% for open arch repair and 5.3% for a-BEVAR (P = 0.220). The stroke rate was 5.3% for open arch repair and 3.5% for a-BEVAR (P = 0.650). Open arch repair was associated with significantly higher rates of prolonged (>48 h) intubation (28.1% versus 3.5%; P < 0.001), acute kidney injury (31.6% versus 8.8%; P = 0.002), and temporary dialysis (22.8% versus 7.0%; P = 0.002). The median hospital length of stay was 21 days for open arch repair and 10 days for a-BEVAR (P < 0.001). During a median follow-up of 30 months (i.q.r. 7-49), no difference in mortality was observed (10.5% for open arch repair versus 12.3% for a-BEVAR; P = 0.770). CONCLUSION:a-BEVAR provides a less invasive alternative to open arch repair with reduced complications. Long-term studies are needed.