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Squizzato et al. Vessel Plus 2023;7:16 https://dx.doi.org/10.20517/2574-1209.2023.05 Page 11 of 14

Figure 9. CTA showing an acute TBAD in a highly angulated type III aortic arch with no adequate sealing zone in zone 1 or 2, and
requiring an extensive coverage of the aortic arch with a proximal landing zone in zone 0 (A). Final result 3D reconstruction of the
hybrid treatment with a single branched arch endograft and supra-aortic trunks debranching (right common carotid artery-left
subclavian artery bypass and left common carotid artery reimplantation on the graft) (B).

Figure 10. Left subclavian artery coverage can be a valid option to gain a more appropriate proximal sealing zone both in terms of length
and aortic healthy wall. Urgent LSA coverage appears to be safe in the treatment of aortic blunt traumatic injuries.

The main anatomical limitations to the use of arch endografts are represented by the presence of a
mechanical aortic valve, a short ascending aorta < 30-40 mm (depending on the endograft type), or a large
ascending aorta > 40 mm in diameter [Figure 9].

Blunt traumatic aortic injuries
A short landing zone may be sufficient for traumatic aortic injuries since the adjacent aorta is essentially un-
diseased. However, it has also to be considered that traumatic injuries often occur in young patients, with
angulated (“gothic”) aortic arches and associated unfavorable displacement forces, and at the same time, it
may be advocated to guarantee long-term durability. Intentional LSA coverage, followed by eventual LSA
revascularization in a second-stage procedure, has been proven to be safe in the urgent setting without the
[39]
risk of major neurological complications or spinal cord ischemia [Figure 10]. However, the long-term
results after TEVAR for traumatic injuries are still not completely clear.