Avoiding cutdown during endovascular arch repair: results of the branch-to-branch-to-branch technique

BACKGROUND: To describe the feasibility and outcomes of the transaxillary branch-to-branch-to-branch carotid catheterization technique for aortic arch endovascular repair. This technique optimizes endovascular procedures and eliminates the need for carotid artery cutdown during surgery. METHODS: This was a single-center, retrospective observational study. The technique involves using a through-and-through guidewire from the right axillary artery to one of the femoral arteries to cannulate the left carotid artery from the axillary access, by turning the sheath, avoiding carotid cutdown. The primary endpoint of the study was technical success, defined as successful completion of the planned procedure with patent target vessels, no intraoperative death and no type I or III endoleaks. Secondary endpoints included mortality, major and minor strokes, spinal cord ischemia, and freedom from reintervention. RESULTS: Between March 2022 and October 2024, thirty-two patients underwent endovascular aortic arch repair at our center, fifteen of whom attempted the transaxillary branch-to-branch-to-branch carotid catheterization technique. Thirteen succeeded: one patient died intraoperatively and one patient underwent a secondary left carotid cutdown. No patients experienced a major stroke, one had a minor stroke, one had late-onset paraplegia. Two patients showed an endoleak at the final angiography, requiring immediate coil embolization of the aneurysm. Reinterventions were performed in three patients: one for endoleak type Ic and two to complete the endovascular treatment of the thoracoabdominal aorta. CONCLUSIONS: This is the first series of patients undergoing endovascular aortic arch repair using the transaxillary branch-to-branch-to-branch carotid catheterization technique to cannulate all supra-aortic vessels. Avoidance of cervical approach reduces operative trauma, potential morbidity and the length of hospital stay.