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Page 8 of 13 Jubouri et al. Vessel Plus 2023;7:5 https://dx.doi.org/10.20517/2574-1209.2022.49

[46]
feasible in 24.9%, 13.6%, and 5.2% of cases respectively . They suggest that TER was only feasible in 5% to
41% of patients in their series of 213 patients with arch aneurysms using fenestrated or branched
[46]
endoprostheses . A summary of the findings in the above subsection can be found in Table 3.

Mortality
Having traded median sternotomy for peripheral arterial cannulation, and hypothermic circulatory arrest
and cardiopulmonary bypass for simple general anaesthesia, TER is associated with improved early and
long-term mortality rates relative to OSR [40,41] .

Singh et al. report a 30-day mortality rate of 2.7% (n = 4) but 0 mortalities during the remainder of their
follow-up period . In contrast, Alsafi et al. report a 9.5% (n = 2) in-hospital mortality rate in their cohort of
[40]
21 . The RESTORE I and II trials were published earlier, reporting on different configurations of the
[41]
RELAY™ device indicated for various aortic pathologies. The RESTORE I trial reported an in-hospital
mortality of 7.2% (n = 19). This rate went lower in the RESTOE II trial featuring in-hospital mortality of 4%
(n = 7) [47,48] . Additionally, Azuma et al. revealed a 1.5% (n = 6) 30-day mortality rate associated with Najuta™,
while Sato et al. reported a 0% in-hospital mortality rate [42,43] . However, four deaths occurred during follow-
[43]
up due to malignancy and retrograde type A aortic dissection . Spear et al. report a promising 0%
mortality rate associated with Zenith™, but a 3.7% 1-year aortic-related mortality . O’Callaghan et al.
[38]
highlight a 7% (n = 1) in-hospital mortality in patients who underwent TER with custom Cook Zenith™ and
18% (n = 3) in patients who received the non-custom endoprosthesis for proximal thoracic aneurysms .
[49]
[45]
Interestingly, Roselli et al. found no mortalities using the Valiant™ endoprosthesis . A summary of the
findings in the above subsection can be found in Table 4.

Neurological injury
Neurological injury in the setting of aortic arch repair results primarily from ischaemia. The aetiology of
cerebral injury in the context of endovascular arch repair is usually embolisation of endoluminal particulate
matter (e.g., atheromatous plaque) during endovascular manipulation, or inadvertent occlusion of the
carotid arteries by endovascular instrumentation [45,50] . Furthermore, spinal cord injury often occurs
secondary to intercostal artery coverage by the endograft leading to compromised perfusion . There is also
[51]
a risk of vertebrobasilar insufficiency in patients that undergo total endovascular arch repair where the left
subclavian artery is occluded and not revascularized .
[52]

Alsafi et al. report a 14% (n = 3) and 5% (n = 1) incidence of stroke and paraplegia following implantation of
Relay™ Branched for TER . Tan et al. also used Relay™ Branched in their study of 148 patients , which
[41]
[53]
yielded a 4.1% (n = 6) stroke rate. The RESTORE I trial found that the incidence of stroke and paraplegia
was 1.6% (n = 5) and 2% (n = 6), respectively, while this was 0.6% and 2.9% in RESTORE II. Azuma et al.
noted that 1.8% (n = 7) of patients undergoing TER with Najuta™ suffered postoperative stroke and 0.8%
(n = 3) paraplegia . Using the same endograft, Sato et al. found that 16.7% (n = 6) of patients implanted
[42]
with Najuta™ suffered a postoperative stroke , while 2.8% (n = 1) suffered postoperative paraplegia.
[43]
Similarly, Iwakoshi et al. highlight 1 case (3.1%) of cerebral infarct and 1 case (3.1%) of spinal cord injury
(SCI) following TER with Najuta™ . Using Zenith™, O’Callaghan et al. report a total of 2 (6%) cases of
[44]
postoperative cerebrovascular accident and 2 (6%) of SCI . Similarly, Spear et al. found 2 (7.4%) cases each
[49]
of postoperative stroke and SCI following TER with Zenith™ . Finally, none of the 9 patients in the
[38]
Valiant™ endoprosthesis study by Roselli et al. experienced major strokes perioperatively . A summary of
[45]
the findings in the above subsection can be found in Table 5.