Outcomes after Endovascular Arch Repair in Patients with a Native Ascending Aorta Diameter Greater than 38 mm: An Observational Study in Two High Volume Centres.

Abstract

This study aimed to evaluate early outcomes of endovascular aortic arch repair using custom made stent grafts in patients with a native ascending aortic diameter > 38 mm. This two centre, retrospective observational study included all consecutive patients who underwent endovascular arch repair with custom made arch branched stent grafts for a native ascending aorta diameter > 38 mm. From July 2018 to April 2025, 228 patients were treated with an arch branch device; 25 of these patients (median age 68.9 years; 68% men) with a native ascending aorta diameter > 38 mm (mean 41.28 ± 2.94 mm) (14% of total cohort) underwent endovascular arch repair for thoracic aortic aneurysm (n = 19, 76%), aortic dissection (n = 3, 12%), or penetrating ulcer (n = 3, 12%). Nine procedures (36%) were performed under urgent conditions. The mean proximal oversizing was 13%. Technical success was achieved in 96%, with one intra-operative death caused by retrograde type A dissection. No intra-operative stroke or type I or III endoleak was observed. Within 30 days, major and minor strokes occurred in 8% (n = 2) and 12% (n = 3) of patients, respectively. Spinal cord ischaemia and retrograde type A dissection were each observed in three cases. The 30 day mortality rate was 40% (elective 24%, n = 6; urgent 16%, n = 4). Aortic related deaths included retrograde type A dissection (n = 3) and cardiac tamponade (n = 2). Myocardial infarctions (n = 2) were also observed. Additional deaths were attributed to stroke, pulmonary embolism, or unknown causes. Most deaths occurred within the first post-operative week. Endovascular arch repair using custom made branched endografts in patients with a dilated native ascending aorta (> 38 mm) is technically feasible but often performed in urgent settings and associated with substantial early morbidity and mortality. These findings underscore the importance of careful patient selection, meticulous planning, and performance in experienced aortic centres where open repair should be considered when feasible. Continued device optimisation is essential before wider clinical application.