Great vessel management for endovascular exclusion of aortic arch aneurysms and dissections

Objectives. To evaluate a recent approach for the endovascular repair of thoracic aortic aneurysms and dissections involving the aortic arch in high risk patients (HRP). Methods. Amongst 102 thoracic aortic aneurysms and dissections, we treated 25 patients for aortic arch endovascular exclusion after transposition of the great vessels, of which 14 (56%) had thoracic aortic arch aneurysms and 11 type A and B chronic aortic dissections. Total transpositions were done in 15 cases (60%) and hemi-arch transpositions in 10. We then used Talent (R), Excluder (R) and Zenith (R) endografts in 12, seven and six cases, respectively. Results. Surgical transpositions were complicated by one minor stroke, which worsened to a major stroke (4%) after endovascular exclusion. After endovascular exclusions, two patients (8%) died from catheterization related complications. One patient had a delayed minor stroke (4%). The successful exclusion rate was 92%. During follow-up (15 +/- 5.8 months), one patient (4%) developed unilateral limb palsy, successfully treated by CSF drainage. The late exclusion rate remained 92%. No stent-related complications were seen. Conclusions. Transposition of supra-aortic vessels allows the endovascular exclusion of the aortic arch in HRP. Aortic endografting after surgical transposition proved to be feasible and offers good mid-term results. Specialized surgical centers with both endovascular and surgical expertise are required to treat these patients.