Endovascular reconstruction of the aortic arch with new-generation dual-branch and triple-branch endograft: design, applicability, indications, outcomes, and future directions

ABSTRACT

Introduction

Repair of aortic arch pathologies such as degenerative aneurysms and dissections still represents a significant challenge for vascular and cardiac surgeons. We focused on the design, evolution, implementation, and prospects of endovascular dual branch technology for treatment of pathologies in the aortic arch.

Areas covered

The literature search was conducted in a non-systematic fashion through the PubMed and Scopus databases; articles deemed relevant to the scope of the work and fully published in English language from January 12,000 until December 2023 were considered for inclusion. Two companies so far have developed and launched in market a dedicated arch dual branch platform: Terumo Aortic and Cook Medical.

Expert opinion

A common limitation to the available technology is represented by the fact that urgent cases (i.e. large or rapidly growing aneurysms, symptomatic patients) cannot be treated because the customization process generally takes between 6 and 8 weeks, and there is an inherent risk for aorta-related adverse events to happen during the waiting time. While the future holds much promise, several technical hurdles still exist and further developments (in device design, operators’ skills, patients’ selection, and outcomes assessment) are needed to establish the safety and effectiveness of treatment particularly over the long-run.

KEYWORDS:

• Aortic disease
• aortic dissection
• aortic aneurysm
• thoracic endovascular aortic repair
• stent-graft

Article highlights

• The use of thoracic endovascular aortic repair (TEVAR) with newer custom-made devices is currently accepted as an established treatment modality for management of aortic arch disease, showing satisfactory technical and clinical outcomes in this complex patient’ population.

• Two companies so far have developed and launched on market a dedicated arch dual branch platform: Terumo Aortic and Cook Medical. However, some structural differences between these two devices may slightly differentiate their anatomical applicability.

• While these were initially indicated solely for patients at high risk for open surgery, their use could be further expanded also for low-risk and middle-risk patients with suitable anatomy in high-volume referral centers.

• A common limitation to the available technology is represented by the fact that urgent cases (i.e. large or rapidly growing aneurysms, symptomatic patients) are intended to be excluded because the customization process generally takes between 6 and 8 weeks, and there is an inherent risk for aorta-related adverse events to happen during the waiting time.

• While the future holds much promise, several technical hurdles still exist and further developments (in device design, operators’ skills, patients’ selection and outcomes assessment) are needed to establish the safety and effectiveness of treatment particularly over the long-run.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

One reviewer is a consultant and scientific advisory board member of Cook Medical, Terumo Aortic, and W.L. Gore & Associates, who manufacture arch branch stent grafts. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.