This compilation of clinical cases is meant as a companion to the 2018 European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) expert consensus document addressing current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch [1]. This document will help translate the recommendations given in the main manuscript into clinical practice with a particular emphasis on the small details that often guide the decision in the direction of open surgery or endovascular therapy or sometimes towards conservative treatment when general conditions put the likelihood of survival or a quality-of-life benefit of aortic treatment into perspective. The main document introduced a modified terminology for better describing the extent of repair by using the Ishimaru attachment zones not only as a reporting standard for endovascular procedures but also for replacement/exclusion from circulation for open procedures [2] as shown in Fig. 1. Definition of attachment zones, also known as Ishimaru zones. Printed with permission from © Campbell Medical Illustration. A 73-year-old man undergoes annual computed tomography angiography (CTA) surveillance of an atherosclerotic aortic arch aneurysm that was detected by chance when a chest radiograph was performed for unspecific pain 5 years ago. Within the last year, a diameter increase of 6 mm that now equals a maximum diameter of 57 mm was detected. The patient is clinically asymptomatic. Due to size and progression, therapy is recommended. The patient undergoes a full cardiovascular workup including a new electrocardiogram (ECG)-triggered CTA starting cranially including the circle of Willis and extending below to the level of the femoral heads. Furthermore, coronary angiography, transthoracic echocardiography (TTE) and duplex scanning of the supra-aortic branches are done. The aortic arch aneurysm is accompanied by a proximal ascending aortic dilatation up to 47 mm in the mid ascending aorta and 55 mm at the level of the offspring of the brachiocephalic trunk (BCT). At the transition between zone 2 and zone 3, the diameter is 38 mm. The morphology of the arch is a type III aortic arch, and the distance between the sternal notch and the left subclavian artery (LSA) is 5 cm, which should enable sufficient exposure of the entire aortic arch pathology via a median sternotomy. The maximum diameter of the aortic root is 38 mm. There is moderate to heavily calcified aortic valve stenosis and a 90% complex stenosis of the left anterior descending coronary artery (LAD). Biventricular function is normal and the remaining valvular status shows morphologically and functionally regular findings. The supra-aortic vessels are free from haemodynamically significant lesions. It is recommended that the patient undergoes an open ascending and aortic arch replacement and a left internal mammary artery bypass (LIMA) to the LAD. Finally, the aortic valve is replaced with a biological prosthesis. The aortic arch is replaced with a branched graft to eliminate the largest possible amount of native diseased aortic arch tissue and to reduce the risk of any kind of suture aneurysm caused by a trade-off in leaving native aortic arch tissue in place. CTA shows that zone 3 is still diseased with a maximum diameter of 55 mm, and regular diameters are reached again in proximal zone 4. The aortic root diameter is 37 mm; the mid ascending diameter is 45 mm. The valvular status is regular and there is no coronary heart disease. It is recommended that the patient undergoes total aortic arch replacement using the frozen elephant trunk (FET) technique including supracoronary replacement of the ascending aorta. The descending anastomosis of the FET prosthesis cuff (at the transition between the surgical prosthesis and the stent graft portion) can be performed proximally in the aortic arch in zone 2 to reduce the risk of palsy of the left laryngeal nerve and to have better exposure due to the gained proximity, which also eases haemostasis. The stent graft portion of the FET prosthesis should be chosen to treat the entire pathological area in one step or, if any doubt arises regarding the elevated risk of the occurrence of symptomatic spinal cord injury, to treat a short segment with a secondary distal thoracic endovascular aortic repair (TEVAR) extension. Intraoperative aortoscopy during hypothermic circulatory arrest is not mandatory; however, it might be helpful to control the distal landing zone and the stent graft portion during the deployment process. The ascending aortic diameter is 37 mm and the aortic arch aneurysm starts in zone 2 and extends to the transition of zone 4 to zone 5. Revascularization of both the left common carotid artery (LCCA) and the LSA would provide a 2.5-cm long proximal landing zone. It is recommended that the patient undergoes a double transposition of the supra-aortic vessels via an upper median hemisternotomy. This operation includes transposition of the LCCA into the BCT followed by transposition of the LSA into the already transposed LCCA. If there is an isolated offspring of the left vertebral artery (LVA) from the aortic arch, it can be re-implanted to the LCCA or LSA with or without (depending on the local anatomical situation) interposition of the great saphenous vein. Due to the extent to the transition of zone 4 to zone 5, a cerebrospinal fluid (CSF) drain is inserted prior to the procedure to protect the spinal cord. Potentially, an extrathoracic right common carotid-to-LCCA-to-LSA artery bypass could be done, but this type of extra-anatomic rerouting is more prone to occlusion and to erosion into adjacent structures such as the oesophagus and the trachea. Finally, a tracheostomy, if needed, is challenging. The patient has regular ascending aortic dimensions without any signs of atherosclerosis. The pathology ends at the transition between zone 3 and zone 4. CTA shows that the distance between the BCT and the LSA is short, and a double transposition might provide a proximal landing zone of only 1.5 cm in zone 1. There is no coronary heart disease and the valvular status is normal; however, the left ventricular ejection fraction is severely reduced to 25%. The anatomy of the aortic arch, including the diameter of the supra-aortic vessel, is suitable for implantation of a double-branched endograft; distal access vessels are suitable for retrograde delivery of the main portion of the stent graft and proximal access vessels are suitable for bridging stent grafts into the BCT and into the LCCA. Because commercially available prostheses do have 2 branches, the LSA needs revascularization either in advance or, preferably to avoid a second opening of the incision, simultaneously. It is recommended that the patient undergoes a simultaneous LSA-to-LCCA bypass and implantation of a double-branched endograft by retrograde delivery of the main body via the femoral artery and by delivery of the supra-aortic bridging grafts into the BCT and the LCCA via surgical cutdowns over both common carotid arteries. Because the distal landing zone of the stent graft component is at the transition between zone 3 and zone 4, CSF drainage is not deemed necessary for additional spinal cord protection. A 77-year-old man presents with a 65-mm thoracic aortic aneurysm starting immediately distal to the origin of the LSA in zone 3. Five centimetres cranial to the coeliac trunk (CT) in zone 5, the diameter becomes regular again. The diagnosis was made by chance because the patient had a chest radiograph prior to a The patient undergoes a full cardiovascular workup including a new CTA starting including the circle of Willis and extending below to the level of the femoral heads. Furthermore, coronary angiography, and duplex scanning of the supra-aortic branches are done. angiography regular findings. shows and regular valvular and supra-aortic vessels that are free from haemodynamically lesions. The proximal landing zone without any kind of transposition is mm from the distal of the LSA offspring to the of the on the of the aortic The diameters of the ascending aorta and the aortic arch at the level of the proximal landing zone are cm and cm, The LSA-to-LCCA would provide a proximal landing zone of The access vessels for retrograde delivery are of sufficient size and It is recommended that the patient undergoes an LSA-to-LCCA with simultaneous A CSF drain is inserted prior to the procedure to protect the spinal cord. angiography regular findings. shows a function and a and regular valvular and the supra-aortic vessels are free from haemodynamically lesions. of the ascending aorta and the aortic arch at the level of the proximal landing zone are cm and cm, The proximal landing zone without any kind of transposition is mm from the distal of the LSA offspring to the of the on the of the aortic arch, but the LSA-to-LCCA transposition would the proximal landing zone to mm. the patient has an isolated offspring of the from the aortic A more of transposition this transposition due to the isolated would the proximal landing zone to The access vessels for retrograde delivery have sufficient size and It is recommended that the patient undergoes a double transposition to BCT and LSA to LCCA transposition with additional transposition of the with a simultaneous from zone to zone 5. A CSF drain is inserted prior to the procedure to protect the spinal cord. angiography disease with that are for coronary shows severely reduced left ventricular the valvular status is morphologically and functionally regular and the supra-aortic vessels are free from haemodynamically lesions. The proximal landing zone without any kind of transposition is mm from the distal of the LSA offspring to the of the on the of the aortic The diameters of the ascending aorta and the aortic arch at the level of the proximal landing zone are cm and cm, LSA to LCCA double transposition would a sufficient proximal landing but due to the regular ascending aortic total endovascular aortic arch repair with LSA is vessels for retrograde delivery do have a sufficient size and Due to the new of due to left laryngeal nerve the to treatment The to and to it was to therapy is of a CSF drain from therapy to avoid during the The patient undergoes simultaneous LSA-to-LCCA revascularization and branched endovascular aortic arch repair with distal to the entire from zone to zone 5. the CSF drain was on a was performed angiography disease with that are for shows a regular function but also haemodynamically significant aortic stenosis with a that is for aortic valve The proximal landing zone without any kind of transposition is mm from the distal of the LSA offspring to the of the on the of the aortic LSA to LCCA double transposition would a sufficient proximal landing zone. The diameter of the ascending aorta is cm, which total aortic arch because of the risk of retrograde type A aortic vessels for secondary retrograde delivery do have sufficient size and It is recommended that the patient undergoes coronary artery bypass using the saphenous grafts to the and the right coronary revascularization is not because of the for total aortic arch replacement and the risk for biological aortic valve replacement and aortic arch replacement using the FET technique with a short stent graft component in proximal zone 4. a of 6 the patient undergoes to zone 5, had a CSF fluid drain inserted in advance of The patient had prior coronary artery bypass with an The aortic arch is not diseased and has a maximum diameter of 3 The offspring of the from the aortic There are no remaining cardiovascular or and the clinical is It is recommended that the patient undergoes a in the with are A CSF drain is inserted the procedure to protect the spinal cord. A bypass is artery or descending thoracic The aortic arch is the and between the LCCA and the The descending aorta is below the The aneurysm is and the LSA is with a The of the circle of Willis is in advance to the for the for into the during the A patient presents with a proximal descending aortic aneurysm on the of a remaining 5 years type A At that the patient a supracoronary ascending aortic replacement with a At the a replacement was The patient was to due to a of and now had a chest radiograph due to surgery that a a thoracic CTA was performed that the The for aneurysm is to be a between the and the in zone 2 that is functionally as a new The patient undergoes a full cardiovascular workup including a new CTA starting including the circle of Willis and extending below to the level of the femoral heads. Furthermore, performed coronary angiography, and duplex scanning of the supra-aortic CTA shows the remaining of 3 supra-aortic The descending aorta a regular size at the transition between zones 4 and the size of the is mm; there are no between the at the thoracic the the artery and the right artery from the and the left artery from the with a between the at that shows function but moderate aortic with a of 4 mm on a of the coronary The remaining valvular status is morphologically and functionally angiography and duplex scanning of the supra-aortic branches regular findings. It is recommended that the patient undergoes total aortic arch replacement using the FET technique using the short stent graft component for spinal cord extending into the transition between zones 3 and 4 with the to of the entire thoracic aorta with the biological aortic valve replacement to the aortic If a distal is needed, secondary can be performed at a on the of the CTA findings. The from the is not at risk thoracic because the between both will provide the CTA shows the remaining of 3 supra-aortic The descending aorta a regular size at the transition between zones 4 and 5. the shows a at the level of zone 4. The the and the from the The from the with a between the at that A FET is to body a to the entire disease is It is recommended that the patient undergoes total aortic arch replacement using the elephant trunk technique with of the during body hypothermic circulatory arrest as as possible to regular distal and to be to access the elephant trunk component in zone 4 at the second distal open surgical to zone 5 is done. CTA shows no remaining of the supra-aortic and the aortic arch is free from remaining up to zone The descending aorta a regular size at the transition between zones 4 and the size of the is mm; and there are no between the at the thoracic The the and the from the The from the with a between the at that LSA-to-LCCA would a 2.5-cm landing zone for The CTA an circle of Willis with the of a the entire circulation with no arteries. It is recommended that the patient undergoes an LSA-to-LCCA bypass a transposition needs risk in this with extending into zone 5 the aortic diameters are The procedure is performed using a CSF drain to protect the spinal cord. The from the is not at risk thoracic because the between both will provide the CTA shows that the ascending aortic prosthesis has a sufficient of cm, and there is no remaining of the supra-aortic The LCCA has a diameter of mm. The descending aorta a regular size at the transition between zones 4 and the size of the is mm; there are no between the at the thoracic the the and the from the and the from the with a between at that the proximal landing the LSA-to-LCCA or a double transposition would a landing zone of sufficient The valvular status is the left ventricular ejection fraction is severely reduced and the patient has A total endovascular is recommended due to an proximal landing zone of a long ascending graft and a LCCA for of the supra-aortic mm are not because the risk for graft occlusion is LSA-to-LCCA bypass for circulation and for to the spinal cord is distal into zone 5 should be The procedure is performed using a CSF drain to protect the spinal cord. The from the is not at risk thoracic because the between both will provide the A patient with a type aortic presents at the for an expert 6 the type has the The patient no The CTA the of the immediately distal to the LSA The extends the entire aorta and ends in zone The the and the from the and the is from both the and the thoracic from the The diameter of the proximal descending aorta is mm and an increase the last The patient undergoes a full cardiovascular workup including a new CTA starting cranially including the circle of Willis and extending below to the level of the femoral heads. Furthermore, coronary angiography, and duplex scanning of the supra-aortic branches are done. The with CTA in zones 4 and 5, has not of the thoracic aorta from CTA the of the ascending mm in zone mm zone between the distal of the left carotid artery and the mm of the entire aorta in zones 4 and mm and diameter of the in zones 4 and mm and mm, The diameter of the LCCA is mm. CTA and duplex scanning of the supra-aortic stenosis is the circle of Willis is A is an LSA-to-LCCA bypass followed by starting in zone 2 extending into zone 5 is of the LSA origin proximal to the will be performed during the surgical procedure or during the second Due to the of from the and the risk of spinal cord injury, stent graft deployment level is of the treatment will if is to the patient a CSF drain to protect the CTA that the in zones 4 and 5 has not The maximum diameter of the proximal landing zone in zone 2 is mm and the is mm. could be a aneurysm of the ascending aorta extending more mm into the FET is CSF drainage is not but should be on the of the component of the FET prosthesis. The should be of the to the extent of secondary should into distal zone 5 if The in the CTA of zones 4 and 5 is of are the in the The diameter of the aortic arch is mm. surgical repair of the distal arch and the descending aorta via a left is of CSF and and will be A or bypass will be to avoid hypothermic circulatory The aortic arch is for from a direction the and left laryngeal nerve or the and between the LCCA and The aorta is replaced and thoracic are A man is to the because of chest pain and of the left The patient presents with The CTA shows a aortic extending into the aortic arch with of the descending aortic The patient presents a normal The patient undergoes a full cardiovascular including a new CTA starting including the circle of Willis and extending below to the level of the femoral heads. Furthermore, coronary angiography, and duplex scanning of the supra-aortic branches are done. CTA shows in the aortic arch at the between the left common carotid and the extends in the arch up to the distal of the BCT and into the LCCA. The maximum diameter of the ascending aorta is 47 mm. the moderate aortic valve is The remaining valvular status is The function is It is recommended that the patient undergoes total aortic arch replacement using the FET technique including replacement of the ascending aorta and of the biological aortic The anastomosis of the FET prosthesis cuff (at the transition between the surgical prosthesis and the stent graft portion) can be performed in zone 2 to reduce the risk of nerve The stent graft portion of the FET prosthesis should be short is to the to reduce to a the remaining risk of symptomatic spinal cord Because the is to the the short stent graft portion will still of the of into the and in the of the thoracic aorta. CTA shows no of the supra-aortic and the is 2 cm to the There is a retrograde extending into the arch up to zone The ascending aortic diameter is 38 mm, and on the the aortic valve is morphologically and functionally The LSA-to-LCCA would provide a landing zone free of LSA to LCCA and a zone 2 are recommended to the Because the ascending aorta is the risk of retrograde is using a free of the landing will the into the the and eliminate A with a of and presents with chest has CTA an extending from zone 2 to zone 5. There is no or aortic The maximum diameter of the is cm and that of the proximal descending and pain was which the patient the patient was had a CTA with and was for a 3 At the the patient an clinical CTA shows a maximum diameter of the distal aortic arch at the transition of zone 2 to zone 3 of cm with a the has in zone immediately the LSA The descending thoracic aorta has and the diameter of cm has The patient undergoes a full cardiovascular workup including a new CTA starting including the circle of Willis and extending below to the level of the femoral heads. Furthermore, coronary angiography, and duplex scanning of the supra-aortic branches are done. the of the into zone an LSA-to-LCCA bypass a 2.5-cm from the to the distal LCCA a proximal landing zone sufficient for The diameter of the ascending aorta is mm and that of the aortic arch at the level of the proximal landing zone is mm. The diameter of the access for retrograde delivery is mm and Biventricular function is the valvular status is morphologically and functionally normal; the coronary shows regular and the supra-aortic vessels are free from haemodynamically lesions. LSA-to-LCCA and extending from zone 2 to zone 4 are the is A CSF drain is inserted prior to the procedure to protect the spinal cord. CTA shows a maximum diameter of the distal aortic arch at the transition from zone 2 to zone 3 of the is in zone 2 immediately the LSA The maximum diameter of the descending aorta is now cm, regular diameters in zone 5. the a type component has extending into zone normal valve function and a angiography shows a significant stenosis of the right coronary and duplex scanning of the supra-aortic branches shows regular findings. the ascending aorta has a maximum diameter of 45 mm, and transposition of 3 arch vessels would be to a sufficient proximal landing zone for The patient is for coronary artery bypass surgery and an FET procedure using the short stent graft component as the is CSF drain is inserted with the the remaining risk of symptomatic spinal cord is deemed The for a secondary if aortic to be aortic arch rerouting is not because the of total aortic arch rerouting and in with aortic to a ascending aortic has a risk for retrograde type A aortic A man with undergoes CTA for CTA shows a atherosclerotic with diameters of mm in the distal aortic The patient is and has no of aortic There are no of the The patient undergoes a full cardiovascular workup including a new starting cranially including the circle of Willis and extending below to the level of the femoral heads. Furthermore, coronary angiography, and duplex scanning of the supra-aortic branches are done. CTA shows in the distal aortic arch at the at the level of the LSA at the transition from zone 2 to zone 3. The maximum diameters of the ascending the aortic arch and the descending aorta are and mm, the valvular status is normal and in the coronary there is no significant coronary heart disease. revascularization of the LSA will provide a sufficient proximal landing zone of mm, both LSA-to-LCCA and zone 2 are recommended. the of a distance between the LSA and the a double transposition and zone might be recommended. the risk of symptomatic spinal cord injury, a short stent graft is recommended. Because the distal landing zone is in proximal zone 4, CSF drainage might be if there are no thoracic artery offspring at that CTA shows that the distance between the BCT and the LSA is short and that double transposition might provide a proximal landing zone of only The dimensions of the ascending aorta are a maximum There is a stenosis of the and the valvular status and left ventricular ejection fraction are The patient has for years for and the any is challenging. The anatomy of the aortic arch including the supra-aortic vessels is suitable for implantation of a double-branched vessels regular diameters for retrograde stent graft It is recommended that the patient has simultaneous LSA-to-LCCA bypass and implantation of a double-branched endograft by retrograde delivery of the main body via the femoral artery and by delivery of the supra-aortic bridging grafts into the BCT and the LCCA via surgical cutdowns over both common carotid arteries. CTA shows that the diameter of the ascending aorta is mm and that the patient has an aortic valve with moderate stenosis and moderate The left is Furthermore, there is coronary heart disease with significant stenosis in the left and right coronary The is at the level of the LSA at the transition from zone 2 to zone 3. It is recommended that the patient has total aortic arch replacement using the FET technique including replacement of the ascending replacement with a biological aortic valve and revascularization of the coronary arteries. The anastomosis of the FET prosthesis cuff (at the transition between the surgical prosthesis and the stent graft portion) can be performed proximally to the aortic arch in zone or 2 to the aortic for the anastomosis and to reduce the risk of nerve The of the stent graft portion of the FET prosthesis should be short in reduce the remaining risk of spinal cord to a A man presents with and elevated 4 aortic root replacement with a biological and simultaneous ascending and replacement due to Due to during the the and chest was performed for the was and the remaining clinical was therapy was using the The patient undergoes a full cardiovascular workup including a new CTA starting cranially including the circle of Willis and extending below to the level of the femoral heads. to the at can be the prosthesis. At the level of the a can be due to of the distal The is free from A shows on the biological due to and also because the coronary shows regular at the was if the clinical conditions are It is recommended that the patient undergoes surgery with of the and using a root from a and a biological and ascending and replacement using an additional a for the aortic root can be with the of additional can be but the remaining risk of to be therapy is of for from and from and from Medical of this for and from for and and from and from of this for for of for for and The have to in to this
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