What surgical procedures are associated with the arch of the aorta?

From the Guidelines

Surgical procedures associated with the arch of aorta include open surgical repair, endovascular repair, hybrid procedures, and the elephant trunk technique, with the choice of procedure depending on the extent of the disease, patient anatomy, and surgical risk factors 1.

Overview of Surgical Procedures

• Open surgical repair involves a sternotomy or thoracotomy to directly access the aortic arch, replace the damaged segment with a synthetic graft, and reimplant the major branch vessels.
• Endovascular repair uses stent grafts deployed through femoral artery access, which is less invasive but anatomically challenging due to the arch's curvature and branch vessels.
• Hybrid procedures combine open surgical techniques for branch vessel reimplantation with endovascular stenting.
• The elephant trunk technique is used for extensive aortic disease, creating a distal extension of the graft that facilitates later procedures.

Considerations for Procedure Selection

• Patient selection depends on anatomy, comorbidities, and surgical risk factors, with postoperative care focusing on hemodynamic stability, neurological monitoring, and long-term imaging surveillance to detect potential complications or disease progression 1.
• The primary goal for surgical intervention in patients with aortopathies is to prevent aortic dissection or rupture, and surgery is also often needed to correct associated valvular disease 1.
• Aortic arch replacement and thoracoabdominal aortic aneurysm repair carry the highest risk of mortality and postoperative complications, but outcomes are improved by using adjunctive cardiopulmonary bypass techniques such as hypothermic circulatory arrest, retrograde/anterograde cerebral perfusion, and the use of a cerebrospinal drain 1.

Recent Guidelines and Recommendations

• The 2024 ESC guidelines for the management of peripheral arterial and aortic diseases recommend open surgical replacement of the arch in patients with low or intermediate operative risk with an aortic arch aneurysm and recurrent episodes of chest pain not attributable to non-aortic causes 1.
• The guidelines also recommend considering an elephant trunk or frozen elephant trunk procedure in patients undergoing open surgical repair of an aortic arch aneurysm, if the aneurysmal disease extends into the proximal descending thoracic aorta 1.

From the Research

Surgical Procedures Associated with Arch of Aorta

• Aortic arch replacement is a complex surgical procedure that requires arresting the circulation to the body and replacement of the brachiocephalic vessels, with special consideration for protecting the central nervous system 2.
• The procedure involves various techniques, including the island technique, the branched graft technique, and the "Spielvogel" trifurcated graft technique, each with its own advantages 2.
• Hybrid and endovascular techniques, such as thoracic endovascular aortic repair, are also used for the treatment of thoracic aortic aneurysms involving the arch and descending aorta 2, 3.
• A surgical technique for ascending aorta, aortic arch, and descending aorta replacement without cross-clamp, circulatory arrest, or hypothermia has been developed, which provides normothermic replacement with selective cannulation and perfusion of the whole body 3.
• Patient management in aortic arch surgery requires complex care, including preoperative evaluation, initiation and control of cardiopulmonary bypass, cerebral protection strategies, and techniques to protect the abdominal end organs during prolonged operations 4.

Techniques and Strategies

• Selective antegrade cerebral perfusion and operative graft selection are key elements in aortic arch replacement surgery 2.
• The use of β-adrenergic blocking agents and routine surveillance imaging is a common approach for managing thoracic aortic aneurysms, followed by surgical repair when the risk of dissection exceeds the risk for repair 5, 6.
• Surgical techniques for the aortic root, as well as surgical and endovascular management of aneurysm and dissection for different aortic segments, are also important considerations in the treatment of thoracic aortic disease 6.