Supra-aortic trunk anatomy and the limits of off-the-shelf endografts: a narrative review
DOI:
https://doi.org/10.48750/acv.675Keywords:
BEVAR, FEVAR, Endovascular complex repair, Renal stent occlusionAbstract
OBJECTIVE: To review and synthesize current evidence on the anatomical considerations of supra- aortic trunks (SATs) and their impact on the feasibility and design of off- the- shelf (OTS) and custom- made endografts in endovascular aortic arch repair.
METHODS: A narrative review was conducted using PubMed and Scopus databases, focusing on studies evaluating SAT morphology, spatial orientation, and device applicability. Studies addressing clock- face orientation, vessel diameters, inter- branch distances, and anatomical suitability for branched or fenestrated devices were included.
RESULTS: Anatomical studies revealed significant variation in SAT configuration, particularly inter- vessel spacing and clock- face orientation. While some consistency in takeoff angles exists, only a subset of patients met the criteria for current OTS devices. Proposed configurations in planning studies—particularly those involving a large left common carotid artery scallop and left subclavian artery fenestration or inner branches—may cover up to 85–97% of cases. Still, challenges remain due to arch angulation, large ascending diameters, and rotational misalignment in tortuous anatomy. Custom- made devices provide high anatomical conformity but are impractical in urgent settings due to production delays.
CONCLUSIONS: Anatomical variability remains a key limitation in the broader application of OTS devices for total endovascular aortic arch repair. However, strategic graft design may allow a limited set of configurations to accommodate most patient anatomies. Standardized preoperative measurements and continued refinement of device designs are essential to improving procedural success and expanding clinical applicability.
Downloads
References
Spanos K, Haulon S, Eleshra A, Rohlffs F, Tsilimparis N, Panuccio G, et al. Anatomical Suitability of the Aortic Arch Arteries for a 3-Inner-Branch Arch Endograft. J Endovasc Ther. 2021;28:14-9.
Spanos K, Panuccio G, Rohlffs F, Heidemann F, Tsilimparis N, Kölbel T. Technical Aspects of Branched Thoracic Arch Graft Implantation for Aortic Arch Pathologies. J Endovasc Ther. 2020;27:792-800.
Spanos K, Haulon S, Tsilimparis N, Rohlffs F, Panuccio G, Kölbel T. Preoperative Measurements and Planning Sheet for an Endograft With 3 Inner Branches to Repair Aortic Arch Pathologies. J Endovasc Ther. 2019;26:378-84.
Malkawi AH, Hinchliffe RJ, Yates M, Holt PJ, Loftus IM, Thompson MM. Morphology of aortic arch pathology: implications for endovascular repair. J Endovasc Ther. 2010;17:474-9.
Mougin J, Sobocinski J, Kratzberg J, Fabre D, Haulon S. Applicability of a standardized thoracic endograft with a single branch for the left subclavian artery to treat aortic disease involving the distal arch. J Vasc Surg. 2020;72:1516-23.
Mazzaccaro D, Sciarrini M, Nano G. Analysis of origin of the supra-aortic trunks from the aortic arch. J Vasc Surg. 2018;67:399-408.
Liu L, Wang W, Lu Q, Jing Z, Zhang S, Xu B. Morphology of the ascending aorta: a study on 114 Chinese patients. J Interv Med. 2018;1:22-7.
Chassin-Trubert L, Gandet T, Ozdemir BA, Lounes Y, Alric P, Canaud L. Aortic Arch Anatomy Pattern in Patients Treated Using Double Homemade Fenestrated Stent-Grafts for Total Endovascular Aortic Arch Repair. J Endovasc Ther. 2020;27:785-91.
Wilbring M, Rehm M, Chazy T, Amler M, Matschke K, Kappert U. Aortic Arch Mapping by Computed Tomography for Actual Anatomic Studies in Times of Emerging Endovascular Therapies. Ann Vasc Surg. 2016;30:181-91.
Magee GA, Veranyan N, Kuo EC, Ham SW, Ziegler KR, Weaver FA, et al. Anatomic suitability for "off-the-shelf" thoracic single side-branched endograft in patients with type B aortic dissection. J Vasc Surg. 2019;70:1776-81.
Nana P, Spanos K, Dakis K, Giannoukas A, Kölbel T, Haulon S. Systematic Review on Customized and Non-customized Device Techniques for the Endovascular Repair of the Aortic Arch. J Endovasc Ther. 2024;31:505-21.
Gouveia EMR, Fernández Prendes C, Khanafar A, Wanhainen A, Mani K, Rouhani G, et al. Common Designs of Custom-Made Fenestrated Arch Devices and Applicability of an Off-the-Shelf Design. J Endovasc Ther. 2025;32:481-89.
Bosse C, Kölbel T, Mougin J, Kratzberg J, Fabre D, Haulon S. Off-the-shelf multibranched endograft for total endovascular repair of the aortic arch. J Vasc Surg. 2020;72:805-11.
D'Onofrio A, Lachat M, Mangialardi N, Antonello M, Schelzig H, Chaykovska L, et al. Three-year follow-up of aortic arch endovascular stent grafting with the Nexus device: results from a prospective multicentre study. Eur J Cardiothorac Surg. 2022;63: e2ac561.
Spath P, Campana F, Tsilimparis N, Gallitto E, Pini R, Faggioli G, et al. Outcomes of Fenestrated and Branched Endografts for Partial and Total Endovascular Repair of the Aortic Arch - A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg. 2024;67:106-16.
Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, et al. EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg. 2024;65:e2ad426.
Spanos K, Tsilimparis N, Rohlffs F, Wipper S, Detter C, Behrendt CA, et al. Total endovascular arch repair is the procedure of the future. J Cardiovasc Surg (Torino). 2018;59:559-71.
Johnson CE, Zhang L, Magee GA, Ham SW, Ziegler KR, Weaver FA, et al. Periscope sandwich stenting as an alternative to open cervical revascularization of left subclavian artery during zone 2 thoracic endovascular aortic repair. J Vasc Surg. 2021;73:466-75.
Wu M, Zhao Y, Zeng Z, Bao X, Li T, Feng R, et al. Mid-term Comparison of One-Piece Branched Stent-Graft and Chimney Technique Treating Aortic Arch Pathologies. Cardiovasc Intervent Radiol. 2022;45:733-43.
Charbonneau P, Kölbel T, Rohlffs F, Eilenberg W, Planche O, Bechstein M, et al. Silent Brain Infarction After Endovascular Arch Procedures: Preliminary Results from the STEP Registry. Eur J Vasc Endovasc Surg. 2021;61:239-45.
