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Page 2 of 13 Jubouri et al. Vessel Plus 2023;7:5 https://dx.doi.org/10.20517/2574-1209.2022.49

stroke 0%-16.7% and reintervention 0%-30.3%, using different commercially available endografts. Given its
novelty, further studies with larger cohorts and longer follow-up periods are necessary to solidify the evidence on
TER, taking into account the significant learning curve associated with TEVAR. In addition, studies directly
comparing arch OSR to TER are warranted to determine superiority. This review aimed to highlight the evolution of
aortic arch repair, focusing on TER device development, intervention criteria and clinical outcomes.

Keywords: Thoracic aortic disease, aortic arch, endovascular, endoarch, TEVAR

INTRODUCTION
Open total arch replacement (TAR) remains the gold standard surgical approach for thoracic aortic
pathologies involving the aortic arch. The reported mortality and morbidity for elective aortic arch repair
are highly variable. Culpable to this overwhelming morbidity and mortality variations are correlated to
patients undergoing cardiopulmonary bypass (CPB) and hypothermic circulatory arrest (HCA), in addition
to risks associated with general anaesthesia. The main two techniques for TAR are the conventional
[1]
elephant trunk (CET) and frozen elephant trunk (FET) .

Over the past decade, the thoracic endovascular approach for aortic arch (or endoarch) repair gained
momentum, especially in high-risk population groups, thanks to the innovation and application
instrumented by device technology endograft suppliers and the enthusiasm of endovascular surgeons. As
such, endografts became available for investigational purposes in the aortic arch profile and as part of
investigational device exemption programs. To this effect, certain devices are supplied fenestrated or
scalloped, while others are branched, albeit single-, double-, or triple-branched stent-grafts. Such technology
optimized options for aortic arch repair in high-risk patients who were deemed inoperable, which decreases
[2,3]
the associated risk of perioperative mortality and morbidity . However, reported series on the use of the
endovascular approach in aortic arch profile continued to encounter relatively high complication rates and
poor operative outcomes . This can be partly attributed to revascularization requirement as well as the
[4]
substantial risk of stroke due to wire and device manipulation within the aortic arch aneurysm, which is a
drawback . In addition, this can also be attributed to the high-risk patient population treated. Graft
[5]
patency, re-intervention rates, long-term comparative functionality, and durability of endoarch were
uncertain [2,4,5] . Additionally, surgeon volume-outcome linearity, learning curve, and decision-making were
key factors for total endoarch repair (TER) to be considered sustainable.

In this review, we sought to highlight the TER approach, including device evolution, intervention criteria
and clinical outcomes, and set the scene in a comparative mode to open surgical aortic arch repair as well as
dwell on the current trend of hybridized approaches using FET which evolved from CET.

METHODS
A comprehensive literature search was performed using major search engines (PubMed, Google Scholar,
EMBASE and Scopus) to search all scientific articles published as of July 2022. The search terms used
included: “Aortic Dissection”, “Aortic Aneurysm”, “Conventional Elephant Trunk (OR CET)”, “Frozen
Elephant Trunk (OR FET)”, “Thoracic Aorta”, “Aortic Arch”, “Endovascular”, “Endovascular Arch Repair”.
Additional sources were identified by individually reviewing reference lists of included publications.