The Endovascular Treatment of Aortic Arch Pathologies

Background: The endovascular treatment of pathologies of the aortic arch has become established in recent years, not only as a complementary treatment option but also as an alternative to open surgery for selected patients. The prevalence of thoracic aortic aneurysms is approximately 0.16%.

Methods: In this narrative review, we present the endovascular treatment options for aortic arch disorders.

Results: The endovascular treatment of aortic arch pathologies has been evaluated to date mainly in uncontrolled, retrospective studies. A prerequisite for endovascular treatment of the aorta is the availability of an adequate landing zone in which the stent graft can be anchored both proximally and distally. Stable, asymptomatic aneurysms can be treated conservatively with frequent follow-up. Endovascular aortic arch procedures have high technical success rates (branched thoracic endovascular aortic repair: 96.3%, fenestrated thoracic endovascular aortic repair: 95.7%), a 30-day mortality of 6.3%, and a 30-day stroke rate of 9.4% (weighted average values). The endoleak rates range from 2.6% to 37.6% (weighted average, 19.6%). Especially for patients with a high surgical risk, this minimally invasive method can be used as an alternative to open surgery in specialized centers. Indications must be determined on a case-by-case basis.

Conclusion: The published studies vary widely in case numbers and patient collectives; randomized controlled trials are lacking, as is a direct comparison with open aortic arch replacement surgery. Improvements in aortic arch prostheses enable improved, more individualized treatment; the risk profile of each patient must be considered by the interdisciplinary aorta team along with the advantages and disadvantages of the various available types of prosthesis.

Cite this as: Kunzmann S, Kondov SK, Schlett CL, Lescan M, Czerny M, Kreibich M: The endovascular treatment of aortic arch pathologies. Dtsch Arztebl Int 2026; 123: 163–8. DOI: 10.3238/arztebl.m2026.0003

In recent years, both incidence and prevalence of aortic pathologies have increased (1). Population-based data yield a pooled incidence of thoracic aortic aneurysms of 5.3 cases per 100 000 individuals per year and a prevalence of approximately 0.16% (2). This development is largely due to demographic change, a growing awareness among medical professionals and the general population, as well as to technical advances and the improved availability of modern, non-invasive imaging procedures (3). The current guidelines of the European Association of Cardiothoracic Surgery and the American Society of Thoracic Surgery recommend individualized treatment—ideally, by a multidisciplinary aortic team comprising specialists from cardiovascular surgery, cardiology, radiology, and angiology, as well as experts in human genetics, who can ensure the care of acute and chronic aortic pathologies at any time of the day or night (3, 4, 5). This applies particularly to patients with aortic arch disorders, given that isolated arch pathologies are rare and the ascending and/or descending aorta are usually also involved in the disease process. Stable, asymptomatic aneurysms with a diameter of less than 55 mm can be treated conservatively, with strict blood pressure control, avoidance of blood pressure spikes, and frequent imaging follow-ups. If there is an indication for non-conservative treatment, the aortic team has two invasive treatment options available: on the one hand, endovascular management with a stent graft, and, on the other, open surgical repair of the aortic arch. The latter can be achieved either with a conventional vascular prosthesis or with a hybrid prosthesis that includes an integrated distal stent-graft component, known as the “frozen elephant trunk” (FET). Many centers prefer the latter device because it offers a good landing zone for subsequent management of the descending aorta (6).

Given the continuous technical improvements of endografts and delivery devices, endovascular repair of the aortic arch has increasingly become an established treatment option. It is no longer reserved only for patients at high surgical risk but is also used in specialized aortic centers for a broader patient population, provided anatomical requirements are fulfilled (7).

Pathologies of the aortic arch

The most common pathologies of the aortic arch are acute or chronic aortic dissection and arteriosclerotic diseases of the aorta, such as aortic aneurysm or penetrating aortic ulcer (PAU) (3, 4).

Aortic dissection

Aortic dissection is the separation of the layers of the aortic wall with formation of an intramural hematoma, caused by a tear (entry) in the media, which allows blood to spread and accumulate within the vessel wall. Aortic dissection may be classified as type A aortic dissection with involvement of the ascending aorta, type B aortic dissection with isolated involvement of the descending aorta, and non-A-non-B aortic dissection with involvement of the aortic arch and the descending aorta (without the ascending aorta). The TEM classification system (T, type; E, entry; M, malperfusion) is also used in daily clinical practice to classify the dissection more precisely and to determine appropriate management (8).

Aortic aneurysm

Aortic aneurysm is a dilation (and often also elongation) of all three layers of the aortic wall. If the ascending aorta is involved in the aneurysm, endovascular repair is not possible due to absence of an adequate proximal landing zone.

Penetrating aortic ulcer

A penetrating aortic ulcer (PAU) is an aortic lesion secondary to atherosclerosis, in which an atherosclerotic plaque penetrates through the intima and into the media, thus compromising stability of the aortic wall (4).

Basic principles of endovascular treatment

Endovascular treatment is a minimally invasive procedure used to treat aortic arch pathologies without open surgery or cardiopulmonary bypass. This is usually achieved percutaneously via puncture of both common femoral arteries. Alternative and/or additional access via other arteries is often required, such as the brachial, subclavian, or common carotid arteries.

The cornerstone of endovascular treatment of the aorta is the use of stent grafts, which are advanced over a stiff guidewire using the Seldinger technique under fluoroscopic guidance to the intended landing zone, where they are deployed. The aim is to redirect blood flow through the stent graft to exclude the pathological region from perfusion and, consequently, from blood pressure. The main objective in aortic dissections is occlusion of the primary entry tear in order to prevent blood flow into the false lumen and so, ideally, to promote thrombosis of the false lumen and distal expansion of the true lumen.

A key prerequisite for endovascular treatment of the aorta is the availability of an adequate landing zone in which a stent graft can be anchored both proximally and distally. The landing zone should be placed in a segment of healthy aorta to avoid complications, such as graft migration, retrograde dissection, and endoleaks. If this is not possible, it may be necessary to move the landing zone more proximally to allow access to the aortic arch in cases of descending aorta pathologies. Alternatively, an artificial landing zone may be created using a surgically implanted (hybrid) prosthesis (4, 8). Description of the landing zones corresponds to the so-called Ishimaru zones (Figure 2) (8).

Figure 2

Depiction of the Ishimaru zones using an aortic model based on a computed tomography angiography of the aorta. Created with BioRender https://BioRender.com/3yl2eu6

Anatomical aspects of endovascular treatment involving the aortic arch

Endovascular treatment of aortic arch pathologies poses several challenges. Firstly, these pathologies are rarely confined to the aortic arch but often involve the ascending and/or descending aorta. Unlike in more stable segments of the aorta, where endovascular treatment has since become standard therapy, endovascular management of the aortic arch is made more difficult by high flow velocities, marked shear forces, complex pulsatile and rotational motion patterns during the cardiac and respiratory cycles, and proximity to coronary ostia and aortic valve (4, 9).

Another particular challenge presented by the aortic arch is the origin of the supra-aortic vessels, which cannot be overstented since this would interrupt antegrade blood flow. Therefore, an alternative perfusion strategy is always required for the brachiocephalic trunk and the left common carotid artery (4, 8). Although the left subclavian artery can be overstented during interventions in zone 2, revascularization is still recommended to safeguard perfusion of the arm, cerebellum, and spinal cord (10).

Preservation of supra-aortic perfusion

Preservation of supra-aortic perfusion is essential for endovascular treatment of aortic arch pathologies with stent-graft deployment in zone 0. This can be accomplished surgically during hybrid procedures, in which two or all three supra-aortic branches are revascularized either by transposition or bypass, or endovascularly using fenestrated or branched stent grafts.

Fenestrated grafts have openings and/or cutouts (fenestrations or scallops) that are aligned with the supra-aortic vessels to allow direct perfusion with minimal manipulation. They are particularly suitable for localized lesions along the lesser curvature.

Branched stent grafts contain integrated “inner branches” to supply the supra-aortic vessels, which allow their antegrade perfusion after deployment of the main body and enable subsequent implantation of bridging stent grafts. These procedures are usually performed via the right subclavian artery (or the right common carotid artery) and the left common carotid artery. For triple-branched prostheses, a transfemoral approach is used to place the bridging stent graft into the left subclavian artery. A complete transfemoral insertion is possible with suitable anatomy.

Fenestrated aortic arch repair

Grafts for fenestrated thoracic endovascular aortic repair (f-TEVAR) usually comprise a proximal scallop to accommodate the brachiocephalic trunk and one or more fenestrations for the other supra-aortic branches. This design facilitates targeted alignment with the vessel origins with comparatively little manipulation of the supra-aortic vessels. Even with fenestrated prostheses, it is sometimes necessary to implant bridging stent grafts to ensure adequate perfusion of the supra-aortic vessels.

Branched aortic arch repair

Branched thoracic endovascular aortic repair (b-TEVAR) consist of a main body with one or two antegrade (relative to the direction of blood flow in the aorta) branches for the supra-aortic vessels and, if necessary, an additional retrograde branch for the left subclavian artery. Depending on the type of system, these can be custom-made or are readily available (off-the-shelf). Certain prostheses require surgical debranching of individual supra-aortic vessels before or during implantation.

In situ fenestrations

With in situ fenestration, a conventional stent graft is first inserted, and, in a second step, an opening is created using a laser or a needle. This fenestration is then progressively dilated with a balloon to accommodate a bridging stent graft. Because this procedure requires temporary interruption of perfusion, it is used predominantly to revascularize the left subclavian artery. Figure 1 shows a 3D reconstruction of an in situ fenestration of a stent graft with revascularization of the left subclavian artery using a bridging stent graft.

Figure 1

3D reconstruction of zone 2 in situ fenestration of a stent graft with left subclavian artery revascularization using an implanted bridging stent graft

The limited range of prosthesis types currently available on the European market may restrict treatment options for endovascular management of the aortic arch.

Anatomical requirements

The anatomical requirements for the above-mentioned prostheses vary, but all require a rigorous preselection process to ensure the safe implementation of total endovascular repair of the aortic arch. As a general rule, the femoral access vessel requires a diameter of 7 to 8 mm, and the landing zone should be at least 25 mm long, free of calcification, thrombi, or dissection, and ideally not exceed 38 mm in diameter. Further limitations depend on the angulation of the aortic arch and supra-aortic anatomy (4, 8).

Nowadays, a mechanical aortic valve is no longer a limitation to endovascular management (11). The aortic team should decide whether a patient is suitable for endovascular management.

Advantages and disadvantages of endovascular arch repair

The body of evidence on endovascular treatment of aortic arch pathologies remains limited, with most evidence coming from case reports, case series, and small multicenter studies. Between 2023 and 2025, however, increasingly large case series were published, which contribute to a better characterization of the procedures and clinical outcomes (12, 13, 14, 15). A conclusive assessment compared with open surgery still requires prospective data acquisition and randomized controlled trials. Aortic arch repair can be performed as either open surgery or an endovascular procedure; the decision is made on an individual basis by the interdisciplinary aortic team (8).

Endovascular treatment offers a minimally invasive treatment alternative to open surgery and is conducted without the use of cardiopulmonary bypass. There are limitations, however, including endoleaks, increased periprocedural radiation exposure, stroke risk from manipulation of the supra-aortic vessels, and the frequent need for reintervention within the first postoperative year (7, 16). A further risk is retrograde type A dissection when the graft is inserted into the native aorta. This occurred in 3.9% of patients in Nana et al.’s cohort (17).

The Table provides an overview of outcomes following endovascular aortic arch repair and demonstrates the considerable heterogeneity and the overall small number of cases across the available trials. Case reports with fewer than five patients were not included. Firm conclusions remain difficult to draw due to limited patient cohorts. The technical success rates, i.e., the correct implantation of all required components with patent target vessels, no type I or III endoleak, and no intraoperative conversion or mortality, are consistently high in all the listed studies, with a weighted average of 96.3% for b-TEVAR and 95.7% for f-TEVAR (13, 14, 15, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33). The 30-day rates for mortality (0–25%, weighted average 6.3%) (12, 13, 14, 15, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34) and strokes (2–26%, weighted average 9.4%) (12, 13, 14, 15, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34) reflect the challenges of the procedure but also emphasize the largely acceptable safety profile of endovascular aortic arch management.

Table

Overview of studies on endovascular aortic arch repair

In their meta-analysis of open aortic arch replacement, Sef et al. (9 studies, 677 patients) reported a pooled early mortality of 8.7% (95% confidence interval: [5.7; 13]) and a late mortality of 24.9% [19.5; 31.1] (35). It should be noted that the patient cohort was complex and heterogeneous, including patients undergoing emergency interventions, whose outcomes are only partially comparable with those of elective primary procedures.

The follow-up data reported in the studies of the meta-analysis are highly heterogeneous. Regarding endoleaks, for example, Tenorio et al. (21), Tsilimparis et al. (22), Verscheure et al. (23), and Iwakoshi et al. (28) reported only those endoleaks that required reintervention. Sato et al. (29) limit their reporting to type Ia endoleaks, making comparison of outcomes across studies impossible. The reported endoleak rates range from 2.6% (27) to 37.6% (12), with a weighted average of 19.6%. Medium- and long-term results are presented in the Table.

Sef et al., for example, reported reintervention rates after open aortic arch repair ranging from 4.8% to 38.7%, with an average follow-up of 1.1 to 5.1 years (35). Pooled analyses of 15 studies on total endovascular aortic arch replacement involving a total of 273 patients demonstrate a high procedural success rate of 92.5% [85.8; 96.3], with a simultaneous relevant overall mortality at follow-up of 15.7% [8.7; 26.3] and an incidence of cerebrovascular complications of 14.0% [7.6; 24.3] (16, 35). In their study of elective surgical aortic arch replacement using the frozen elephant trunk technique in complex redo situations (n = 63), Berger et al. reported 3% mortality and an 8% incidence of cerebrovascular events (36). In a multicenter study, Kreibich et al. also reported a mortality of 6% for elective surgical aortic arch replacement using the frozen elephant trunk technique for residual dissection after type A dissection (n = 237) (37). These results are comparable to those for endovascular aortic arch repair – particularly in complex redo-situations. A direct comparison of the available data is difficult because patient cohorts and case numbers vary considerably across studies, and prospective, controlled, randomized studies are lacking. The results indicate a significant risk of cerebrovascular complications and a noteworthy reintervention rate for both open and endovascular aortic arch procedures. It should be noted that the reintervention rate depends largely on the initial indication: in certain cases, aortic arch surgery is performed to create an adequate landing zone for subsequent interventions on the descending aorta.

Future perspectives

The technical development of endovascular grafts for aortic arch repair is remarkable and continues to evolve. Many of the existing anatomical limitations are expected to be overcome in the future. Two key developments are likely to shape the next decade in this field: First, the time is ripe for high-quality, methodologically sound studies comparing endovascular procedures and open surgery. Only such studies will identify those patient cohorts that will benefit most from an endovascular approach or for whom it is not suited. Currently, the level of evidence for aortic surgery is insufficient, making robust treatment decisions more difficult. And second, a structured technology transfer will be required – away from custom-made grafts that are time-consuming and resource-intensive towards standardized, readily available, “off-the-shelf” solutions that enable and optimize care of a broader patient population.

Conflict of interest statement
StK has received consulting fees from Lifetech.

The other authors declare that no conflict of interest exists.

Manuscript received on 30 August 2024, revised version accepted on 15 December 2025

Translated from the original German by Dr. Grahame Larkin

Corresponding author:
Dr. med. univ. Sophie Kunzmann

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