Branched and fenestrated endovascular aortic arch repair in patients with native proximal aortic landing zone

Introduction Fenestrated and branched thoracic endovascular repair (f/bTEVAR) have been successfully applied in patients with diverse aortic arch pathologies. The aim of this study is to present the early and mid-term outcomes of patients with native proximal aortic landing (NPAL) managed with f/bTEVAR. Methods A single-center retrospective analysis of patients with NPAL, managed with f/bTEVAR, between September 1st, 2011, and June 30th, 2022, was conducted. All patients were treated with custom-made devices (Cook Medical, Bloomington, IN, USA) with landing within Ishimaru zones 0-2. Primary outcomes were technical success, mortality, stroke, and retrograde type A dissection at 30 days. Follow-up outcomes were considered secondary. Results 126 patients were included (69.8% males; mean age 70.8±4.2 years; 18.2% urgent). The main indications (60.4%) for repair were aortic arch (29.4%) and thoracoabdominal aortic aneurysms (31.0%). Seventy-two (57.1%) patients were managed with fTEVAR. Proximal landing in zone 0 and 1 was chosen in 97.6%. Technical success was 94.4% and 30-day mortality was 11.9%. Strokes were diagnosed in 13.5% of patients and major strokes were identified in 7.9% cases. Retrograde type A dissection rate was 3.9%. The multivariate analysis confirmed landing in Ishimaru zone 0 as an independently related factor for stroke (p=.005) while stroke (p<.001), pericardial effusion (p<.001) and acute kidney injury (p<.001) were independently related to 30-day mortality. Mean follow-up was 17.5±9.3 months. The estimated survival rate and the freedom from reintervention rate were 72.6% (standard error; SE 4.4%) and 46.4% (SE 6.0%) at 24-month follow-up, respectively. Conclusions Stroke rate after endovascular arch repair was alarming among patients with NPAL. Proximal landing to zone 0 was related to higher risk of stroke. Reinterventions were common within the 24-month follow-up.