REVIEW  CRITICAL ISSUES ON DEALING WITH CHRONIC POST-DISSECTION ARCH AND THORACOABDOMINAL AORTIC ANEURYSMS Free access

The Journal of Cardiovascular Surgery 2020 August;61(4):402-15

DOI: 10.23736/S0021-9509.20.11395-8

Copyright © 2020 EDIZIONI MINERVA MEDICA

language: English

Endovascular management of chronic post-dissection aneurysms of the aortic arch

Justine MOUGIN ¹, Philippe CHARBONNEAU ¹, Julien GUIHAIRE ¹, Adeline SCHWEIN ¹, Mark R. TYRRELL ², Blandine MAUREL ³, Dominique FABRE ¹, Stéphan HAULON ¹ ✉

¹ Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France; ² St. Thomas’ Hospital, London, UK; ³ Service of Vascular Surgery, Thorax Institute, Nantes University Hospital, Nantes, France

This article reviews endovascular management of chronic post-dissection aneurysms of the aortic arch. Therapeutic strategies intended for this complex aortic condition are evolving rapidly to allow the treatment of various hostile aortic anatomy and frail patients. Principles, technical considerations, devices and outcomes of each technique are reviewed and summarized. Hybrid repair offer similar early mortality and stroke rates compared to open conventional surgery. Arch chimney and other parallel graft techniques present poor long term outcome, and should be limited to emergency situations where no other option is available. Fenestrated stent-grafting is subjected to many technical challenges in aortic arch due to difficulties in stent-graft orientation and fenestration positioning. In situ fenestration is an off-label technique that should only be used as an emergency bailout maneuver, considering that temporary coverage of supra aortic trunk vessel and its long-term durability raise concern. Finally, in experienced hands and appropriate anatomic conditions, arch branched graft technology has shown itself to be a safe and effective alternative to open conventional surgery. No randomized controlled trials have yet compared total endovascular aortic arch repair with hybrid techniques and open arch repair. The management of chronic post-dissection aneurysms of the aortic arch is challenging, decision-making and interventions should continue to be performed in high-volume centers with a dedicated aortic team with an expertise in both open and endovascular repairs.

KEY WORDS: Aortic arch syndromes; Endovascular procedures; Dissecting aneurysm