Current options and recommendations for the treatment of aortic arch diseases

Introduction

Diseases of the aortic arch represent some of the most complex and challenging conditions in cardiovascular medicine (1,2). Although isolated pathologies limited exclusively to the aortic arch are relatively rare, the arch is frequently involved as part of more extensive thoracic aortic disease (1). Owing to its unique anatomy and the presence of supra-aortic branch vessels supplying the brain, pathological processes affecting the aortic arch are associated with substantial morbidity and mortality, making their management of particular clinical importance (3,4).

The spectrum of aortic arch pathologies is broad and encompasses both acute and chronic conditions. These include acute and chronic aortic dissections, degenerative and post-dissection aneurysms, and atherosclerotic disease such as penetrating aortic ulcers (1). In many patients, these entities extend beyond the arch and involve adjacent segments of the ascending or descending thoracic aorta, further increasing therapeutic complexity and necessitating individualized treatment strategies (1).

Over recent decades, the treatment of aortic arch diseases has undergone substantial refinement (5,6). Advances in open surgical techniques, including improved cerebral protection strategies and hybrid approaches, have significantly enhanced procedural safety (7,8). In parallel, the rapid evolution of endovascular technologies has expanded the therapeutic armamentarium, enabling less invasive solutions for selected patients and anatomical scenarios (6). As a result, treatment selection now requires careful consideration of anatomical characteristics, disease acuity, patient comorbidities, and institutional expertise.

This article aims to provide a comprehensive overview of pathologies involving the aortic arch and to discuss current treatment options and recommendations. By reviewing both open and endovascular approaches, we seek to highlight optimal management strategies for specific anatomical and clinical scenarios and to support informed decision-making in the contemporary treatment of aortic arch disease.

Thoracic aortic pathologies involving the aortic arch

The thoracic aorta is anatomically divided into the aortic root, ascending aorta, aortic arch, and descending thoracic aorta. Among these segments, the aortic arch represents an anatomically limited yet clinically critical portion of the thoracic aorta, defined by the origins of the supra-aortic vessels. Despite its short length, the aortic arch plays a central role in complex thoracic aortic disease, frequently being involved as part of more extensive aortic pathology rather than as an isolated segment (1).

Anatomical classification and reporting standards

To standardize anatomical descriptions and facilitate precise communication in both clinical practice and research, the use of the Ishimaru zoning system is recommended. This classification divides the aorta into 12 zones (0–11 zones), enabling accurate reporting of disease extent, treatment coverage in open and endovascular repairs, extension of aortic dissections, and localization of entry tears or communications between the true and false lumens (1,9). In particular, the Ishimaru zones are indispensable for describing pathology and therapeutic strategies involving the aortic arch and adjacent segments.

In addition to longitudinal zoning, the configuration of the aortic arch itself has important anatomical and hemodynamic implications. Aortic arch anatomy is commonly categorized into types I, II, and III based on the vertical origin of the supra-aortic vessels (10). In a type I arch, all branch vessels originate at the same horizontal level. In type II, the innominate artery originates between the horizontal planes of the outer and inner curvatures of the arch, whereas in a type III arch, the innominate artery arises below the inner curvature. Notably, type III aortic arches are associated with abnormal helical flow patterns and have been shown to occur with increased prevalence in patients with type B aortic dissection, suggesting a potential mechanistic link between arch geometry and disease development (10).

Aortic arch aneurysm

Aneurysms of the aortic arch represent a relatively uncommon manifestation of thoracic aortic aneurysmal disease, with only a small proportion occurring exclusively within the arch (11) (Figure 1A,1B). More frequently, arch aneurysms develop as part of more extensive thoracic aortic disease. The aortic arch is anatomically defined by the origins of the supra-aortic vessels, and even modest dilation in this region may have significant clinical implications due to its proximity to critical mediastinal structures.

Figure 1 Preoperative computed tomography angiography of the thoracic aorta. (A) Coronal reconstruction demonstrating aortic arch pathology involving the ascending aorta and arch. (B) Axial view confirming the extent of the lesion and its relationship to the adjacent mediastinal structures.

The clinical presentation of aortic arch aneurysms is heterogeneous. While many patients remain asymptomatic, symptoms may occur independently of aneurysm size. Compression or displacement of adjacent structures can lead to dyspnea from tracheal involvement and dysphagia due to esophageal compression. In contrast to descending thoracic aneurysms, pain is a less consistent feature of arch aneurysmal disease (11).

In patients with clinically evident symptoms of aortic arch disease, aortic arch repair is recommended regardless of the size of the aneurysm. For patients with isolated aortic arch aneurysms who do not exhibit symptoms, surgical repair should be considered when the aneurysm diameter reaches or exceeds 55 mm (1).

Acute aortic dissection involving the aortic arch

Acute aortic dissection frequently involves the aortic arch, either as a primary site of intimal disruption or as a conduit for propagation between the ascending and descending thoracic aorta. Arch involvement adds substantial anatomical and prognostic complexity and is not fully captured by traditional Stanford or DeBakey classifications, underscoring the importance of contemporary descriptive frameworks in terms of the type-entry-malperfusion (TEM) classification (12).

In acute type A dissection, the aortic arch may be involved through extension of the dissection flap, direct intimal disruption within the arch, or pre-existing or concomitant aneurysmal dilation. An entry tear located in the arch represents a distinct morphological pattern, often associated with complex true- and false-lumen relationships within the supra-aortic vessels and malperfusion (12). In addition, enlargement of the arch, commonly referenced when the diameter exceeds 45 mm, reflects advanced disease and is associated with an increased likelihood of persistent false-lumen flow and later aneurysmal degeneration (13).

Acute type B aortic dissection is defined by the absence of ascending aortic involvement; however, potential treatment options frequently need to extend proximally into the aortic arch. In some patients, the arch plays a dominant role in the disease process due to the proximity of the primary entry tear to the supra-aortic vessels or due to unfavorable arch anatomy and geometry (14).

A subset of acute aortic dissections is characterized by an entry tear located in the aortic arch, with extension into the descending thoracic aorta but without involvement of the ascending aorta. Nowadays described as non-A non-B dissections, these patterns were not explicitly addressed in earlier classification systems (12). Clinically, this dissection phenotype is associated with a high incidence of adverse features, including malperfusion syndromes, rapid aortic expansion, and early rupture (12). The arch location of the entry tear contributes to complex flow patterns and pressurization of the false lumen, which may explain the unfavorable natural history reported in earlier observational series.

Residual aortic dissection after previous type A repair

Residual aortic dissection following surgical repair of acute type A dissection represents one of the most common substrates for late aortic arch pathology. After initial repair, the dissection frequently persists in the arch and descending thoracic aorta, where ongoing false-lumen perfusion may drive negative aortic remodeling (15).

Two major pathological mechanisms dominate in this setting. The first is progressive diameter enlargement of the residual dissected aortic arch, often occurring over years and reflecting chronic false-lumen pressurization (15). The second is the development of new intimal disruptions at the distal anastomosis, commonly referred to as distal anastomotic new entry tears (16). These lesions can re-establish or augment false-lumen flow and are strongly associated with accelerated aneurysmal degeneration of the arch and distal thoracic aorta. In this scenario, subsequent, and sometimes multiple, distal reinterventions are common (Figure 2A,2B).

Figure 2 Postoperative computed tomography angiography following total aortic repair and replacement. (A) Three-dimensional volume rendering demonstrating the FET graft with incorporation of the supra-aortic branches and the distal extension into the descending thoracic as well as abdominal aorta. (B) Maximum intensity projection confirming patency of the supra-aortic and thoracoabdominal branches with preserved distal aortic perfusion. FET, frozen elephant trunk.

Treatment options for aortic arch pathologies

Treatment of aortic arch pathologies comprises various modalities ranging from guideline-directed medical therapy to endovascular aortic arch repair, including varying extents of supra-aortic debranching to create a sufficient proximal sealing zone, and up to open surgical partial or total aortic arch replacement using hypothermic circulatory arrest (1). While guideline-directed medical therapy is beneficial as adjunctive therapy to endovascular or open procedures, its durable long-term preventive effect in reducing aortic events is limited. Nevertheless, it plays an important role in blood pressure control and pain relief.

Endovascular aortic arch repair

Branched thoracic endovascular aortic repair (B-TEVAR)—custom-made solutions

The expertise gained from branched endografts used in the treatment of thoracoabdominal aortic pathology has been transferred to the endovascular treatment of the aortic arch. Currently, custom-made stent grafts with inner branches are used. After implantation of the main body, these devices allow continuous antegrade blood flow to the supra-aortic vessels, facilitating straightforward cannulation of the branches and implantation of bridging stent grafts (17).

Examples of devices with inner branch designs include the Cook Arch Branched Endograft (Cook, Bloomington, IN, USA) and the Relay Branch (Terumo Aortic, Sunrise, FL, USA) (17,18).

Implantation of a B-TEVAR can be performed with either two or three branches. The third branch for the left subclavian artery (LSA) represents a retrograde branch (19).

Another option for B-TEVAR in the treatment of the aortic arch is the device from Lifetech (Shenzhen, China), which can also be manufactured with three branches. In addition, this prosthesis contains a nitinol support mesh along the greater curvature of the aorta to enhance stabilization (19) (Figure 3).

Figure 3 Pre- and post-procedural angiography of total endovascular branched aortic arch repair using the Concave EndoArch device. Pre-implantation angiography demonstrates device positioning landmarks, while final angiography confirms successful exclusion of the aortic arch pathology and patency of all supra-aortic branches through dedicated bridging stent grafts. (A) Angiography before implantation of a branched endovascular arch device (Concave, Shenzhen, China) using a Lunderquist guidewire (Cook Medical, Bloomington, IN, USA) without crossing the aortic valve. The arrows indicate the radiopaque ring markers marking the proximal and distal ends of the tunnel housing the inner branches for the supra-aortic vessels. (B) Final angiography following total endovascular branched aortic arch repair using a branched arch device with two antegrade inner branches for the innominate artery and left common carotid artery, and one retrograde branch for the LSA. The endoarch device incorporates dedicated low-profile, self-expanding bridging stent grafts. LSA, left subclavian artery.

B-TEVAR—off-the-shelf solutions

In addition to custom-made B-TEVAR devices for the aortic arch, branched endografts that are immediately available are now on the market.

One example is the Gore Thoracic Branch Endoprosthesis (Gore Medical, Newark, DE, USA), which allows landing in zone 2 without requiring a bypass from the left common carotid artery (LCCA) to the LSA. It can also be used for zone 0 landing after transposition of the LCCA and LSA to the brachiocephalic trunk (BCT). In this system, the branch for the LSA is implanted using an additional guidewire introduced into the LSA (20).

Another prosthesis with an external branch for the LSA is the Castor stent graft (MicroPort Endovastec, Shanghai, China), which also permits landing in zone 2 without the need for an LCCA-LSA bypass.

An additional option for the aortic arch is the bimodular Nexus stent graft system (Artivion EMEA, Hechingen, Germany). This device consists of two components: a stent graft for the ascending aorta and a second component for the aortic arch with an external branch for the BCT (21).

Fenestrated thoracic endovascular aortic repair (F-TEVAR)—custom-made solutions

Treatment with F-TEVAR is particularly suitable for lesions located along the lesser curvature of the aorta. Compared with B-TEVAR, this technology is associated with shorter procedural times and fewer manipulations of the supra-aortic vessels. Consequently, the literature reports a lower incidence of stroke in this patient cohort (22).

Various prosthesis configurations with fenestrations and scallops have been developed, allowing landing between zones 0 and 2, thereby achieving a longer proximal landing zone.

Stent grafts from Cook Medical and Terumo Aortic incorporate fenestrations; however, these still require additional bridging stent grafts.

Terumo Aortic also offers a prosthesis with a large scallop, in which part of the graft fabric is removed along the greater curvature of the aorta to accommodate the origins of the supra-aortic vessels.

Another option for F-TEVAR in the aortic arch is the Najuta stent graft (Kawasumi Laboratories, Tokyo, Japan). This endoprosthesis has a unique design consisting of an endoskeleton covered with polytetrafluoroethylene (PTFE) and includes fenestrations for the supra-aortic vessels without the need for bridging stent grafts (23).

The device requires a different implantation technique, in which passage across the aortic valve is not necessary (Figure 4). In the Najuta procedure, a through-and-through wire is established between the common femoral artery and the right brachial artery. Using a loop positioned at the level of the aortic valve, optimal adaptation of the stent graft to the lesser curvature of the aorta can be achieved (23).

Figure 4 Fenestrated thoracic endograft implantation for total endovascular aortic arch repair. (A) High-definition angiography showing the implantation of a fenestrated thoracic endograft (Najuta, Kawasumi Laboratories, Tokyo, Japan) with the use of a loop over the aortic valve without crossing it. The arrow indicates the soft guidewire, which does not require crossing the aortic valve. (B) A three-dimensional reconstruction after endovascular aortic arch repair with a fenestrated endograft without the use of bridging stent-grafts.

F-TEVAR—off-the-shelf solutions

One off-the-shelf option is in-situ fenestration, which is performed antegrade after deployment of the stent graft. Several techniques are available for creating the fenestration, including laser fenestration or needle fenestration (24) (Figure 5).

Figure 5 Guide wire-induced in-situ fenestration. (A) The arrow indicates the positioned bridging stent-graft through the in-situ fenestration. (B) The arrow indicates the flaring of the bridging stent-graft in the area of the in-situ fenestration.

In-situ fenestration may be considered in patients who are not suitable for open surgical repair and who cannot wait for a custom-made device due to medical urgency.

However, it should be noted that this technique intentionally damages the graft fabric during fenestration, after which a bridging stent graft is implanted through the created defect. Over the long term, this may lead to structural failure at the connection sites. Currently, evidence regarding the long-term outcomes of this technique remains limited (25).

Open aortic arch replacement

Open surgical replacement of varying extents of the aortic arch remains the standard of care for the majority of aortic pathologies involving the aortic arch in patients who are considered operable. Patients with aortic arch aneurysms rarely present with isolated arch disease; instead, adjacent proximal and/or distal aortic segments are commonly involved. The proximal aortic arch may be affected in ascending aortopathies and is classified as the ascending extended phenotype. This phenotype is associated with stenotic right-noncoronary cusp fusion type bicuspid aortic valve (26-28). In this specific scenario, hemiarch replacement with an open distal anastomosis is sufficient in the majority of cases.

If aortic wall quality is unsatisfactory or the aortic diameter at the intended distal anastomotic site is ≥45 mm, extension of the repair to a partial arch replacement, including reimplantation of one or more supra-aortic vessels, is indicated (1). When this diameter threshold is exceeded at the level of the distal aortic arch or proximal descending aorta, total aortic arch replacement with antegrade stent-graft implantation into the descending aorta is recommended. This so-called frozen elephant trunk (FET) technique is particularly beneficial in patients with mega-aortic syndrome and extensive thoracic or thoracoabdominal aortic dilation, as it facilitates subsequent endovascular or open distal aortic interventions (29).

In complex cases, staged treatment of the downstream aortic segment using TEVAR extension, followed by open or endovascular thoracoabdominal replacement or repair, may reduce overall surgical trauma and facilitate preconditioning of the intraspinal and paraspinal collateral network, thereby lowering the risk of symptomatic spinal cord injury (29). Outcomes of the FET technique for thoracic aneurysms are generally favorable; however, stroke rates remain higher compared with other chronic settings, such as residual aortic dissection following previous type A repair (30,31).

Open versus endovascular aortic arch treatment

Open aortic arch replacement is indicated in patients with acceptable operative risk profiles, anatomies amenable to open reconstruction, and anticipated longevity sufficient to benefit from the durability of surgical repair. This strategy is preferentially applied in younger patients, those with low to intermediate perioperative risk, and individuals with connective tissue disorders or extensive and complex arch pathology. The procedure requires cardiopulmonary bypass with hypothermic circulatory arrest and adjunctive selective antegrade cerebral perfusion to ensure neurologic protection. Operative duration is considerable, with median times exceeding seven hours, and perioperative blood transfusion is routinely required. Postoperative recovery is associated with prolonged mechanical ventilation, extended intensive care unit admission, and longer overall hospitalization. In elective cases, early mortality remains acceptable, typically ranging from 2.5% to 6%, while perioperative stroke rates are reported at approximately 5–6%. Long-term outcomes favor open repair, with superior overall survival, durable exclusion of arch pathology, low rates of aorta-related mortality, and infrequent need for secondary interventions (23,32-34).

Total endovascular aortic arch repair is generally reserved for patients deemed high or prohibitive risk for conventional open surgery, most commonly elderly individuals with substantial comorbidity burden and limited physiologic reserve. Patient selection is highly dependent on detailed assessment of arch morphology, supra-aortic vessel anatomy, landing zone quality, and compatibility with branched or fenestrated endograft technology, whether custom-manufactured or off-the-shelf. Compared with open reconstruction, endovascular repair is less invasive, characterized by significantly shorter procedural times, reduced transfusion requirements, and minimal need for prolonged ventilation, intensive care, or extended hospitalization. Reported technical success rates exceed 95% with contemporary custom devices. Early mortality appears comparable to open repair; however, neurologic complications, particularly stroke, may occur at higher frequencies, with rates reported up to 14%. In addition, secondary interventions are more common, driven primarily by endoleaks, branch instability, or access-related complications. While mid-term freedom from aorta-related death at 5 years is similar between approaches, overall survival is generally inferior following endovascular repair, and reintervention rates are higher, particularly in cases requiring proximal landing in zone 0 or 1 (23,32,35).

Conclusions

In summary, open aortic arch replacement remains the reference standard for appropriately selected, medically fit patients, offering durable repair and superior long-term aorta-specific outcomes. Total endovascular arch repair represents an important complementary strategy for patients at elevated surgical risk, achieving reduced perioperative morbidity at the expense of higher reintervention rates and less predictable neurologic outcomes.

Acknowledgments

Large language models and wrappers have been used for spell-checking and grammatical amplification.

Footnote

Funding: None.

Conflicts of Interest: M.C. is a shareholder of TEVAR Ltd. and Ascense Medical. M.G. reports consultancy fees from Artivion. M.L. is proctor and consultant for Terumo Aortic, Artivion, and Lifetech. S.K. is proctor for Lifetech and Kawasumi, and reports speaking honorarium from Artivion. The other authors have no conflicts of interest to declare.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Authors/Task Force Members. EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ. Ann Thorac Surg 2024;118:5-115.
2. Mazzolai L, Teixido-Tura G, Lanzi S, et al. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 2024;45:3538-700. [Crossref] [PubMed]
3. Fukuhara S, Norton EL, Chaudhary N, et al. Type A Aortic Dissection With Cerebral Malperfusion: New Insights. Ann Thorac Surg 2021;112:501-9. [Crossref] [PubMed]
4. Pitts L, Hülsenberg L, Montagner M, et al. A Type-Entry-Malperfusion-Based Propensity Score Matched Analysis Depending on Surgical Expertise in Patients Without Malperfusion Undergoing Surgery for Acute Type A Aortic Dissection. Interdiscip Cardiovasc Thorac Surg 2026;41:ivag020. [Crossref] [PubMed]
5. Shrestha M, Beckmann E, Krueger H, et al. The elephant trunk is freezing: The Hannover experience. J Thorac Cardiovasc Surg 2015;149:1286-93. [Crossref] [PubMed]
6. Willot C, Forcillo J, Blair JF, et al. Total percutaneous 4-vessel endovascular aortic arch repair with a triple inner-branch device and a fenestration. JTCVS Tech 2024;28:18-21. [Crossref] [PubMed]
7. Czerny M, Schmidli J, Carrel T, et al. Hybrid aortic arch repair. Ann Cardiothorac Surg 2013;2:372-7. [Crossref] [PubMed]
8. Tsagakis K, Osswald A, Weymann A, et al. The frozen elephant trunk technique: impact of proximalization and the four-sites perfusion technique. Eur J Cardiothorac Surg 2021;61:195-203. [Crossref] [PubMed]
9. Ishimaru S. Endografting of the aortic arch. J Endovasc Ther 2004;11:II62-71. [Crossref] [PubMed]
10. Rylski B, Pacini D, Beyersdorf F, et al. Standards of reporting in open and endovascular aortic surgery (STORAGE guidelines). Eur J Cardiothorac Surg 2019;56:10-20. [Crossref] [PubMed]
11. Berger T, Dumfarth J, Kreibich M, et al. Thoracic aortic aneurysm. Nat Rev Dis Primers 2025;11:34. [Crossref] [PubMed]
12. Rylski B, Pérez M, Beyersdorf F, et al. Acute non-A non-B aortic dissection: incidence, treatment and outcome. Eur J Cardiothorac Surg 2017;52:1111-7. [Crossref] [PubMed]
13. Berger T, Maier A, Kletzer J, et al. Radiographic complicated and uncomplicated descending aortic dissections: aortic morphological differences by CT angiography and risk factor analysis. Eur Heart J Cardiovasc Imaging 2024;25:867-77. [Crossref] [PubMed]
14. Sievers HH, Rylski B, Czerny M, et al. Aortic dissection reconsidered: type, entry site, malperfusion classification adding clarity and enabling outcome prediction. Interact Cardiovasc Thorac Surg 2020;30:451-7. [Crossref] [PubMed]
15. Rylski B, Hahn N, Beyersdorf F, et al. Fate of the dissected aortic arch after ascending replacement in type A aortic dissection†. Eur J Cardiothorac Surg 2017;51:1127-34. [Crossref] [PubMed]
16. Graham NJ, Titsworth M, Ahmad RA, et al. Distal Aortic Progression After Hemiarch, Zones 1-3 Arch Replacement in Acute Type A Aortic Dissection. Ann Thorac Surg 2023;115:888-95. [Crossref] [PubMed]
17. Czerny M, Berger T, Kondov S, et al. Results of endovascular aortic arch repair using the Relay Branch system. Eur J Cardiothorac Surg 2021;60:662-8. [Crossref] [PubMed]
18. Tsilimparis N, Detter C, Heidemann F, et al. Branched endografts in the aortic arch following open repair for DeBakey Type I aortic dissection. Eur J Cardiothorac Surg 2018;54:517-23. [Crossref] [PubMed]
19. Shu C, Wang T, Fang K, et al. Concave Triple Branched Stent Graft System for Aortic Arch Pathologies: A First in Man Prospective Cohort Study. Eur J Vasc Endovasc Surg 2026;71:77-84. [Crossref] [PubMed]
20. Satam K, Fereydooni A, Liu BC, et al. Real-world outcomes of the Gore thoracic branch endoprosthesis in aortic arch zones 0 to 2, with a zone 2 comparison to thoracic endovascular aortic repair with carotid-subclavian bypass. J Vasc Surg 2026;83:1455-1463.e2. [Crossref] [PubMed]
21. Lescan M. Total aortic arch repair between endo and hybrid-the Nexus single-branched endograft. Eur J Cardiothorac Surg 2022;63:ezac594. [Crossref] [PubMed]
22. Spath P, Campana F, Tsilimparis N, 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. [Crossref] [PubMed]
23. Nakamae K, Azuma T, Domoto S, et al. Pre-curved Fenestrated Endovascular Repair Versus Total Arch Replacement for Aortic Arch Aneurysm Repair. J Endovasc Ther 2025; Epub ahead of print. [Crossref]
24. Shang T, Tian L, Li DL, et al. Favourable Outcomes of Endovascular Total Aortic Arch Repair Via Needle Based In Situ Fenestration at a Mean Follow-Up of 5.4 Months. Eur J Vasc Endovasc Surg 2018;55:369-76. [Crossref] [PubMed]
25. Ullery BW, Alie-Cusson F, Magee GA, et al. Laser in situ fenestrated endograft (LIFE) repair of complex aortic arch pathology: Early outcomes from the multicenter LIFE registry. J Vasc Surg 2026;83:647-55. [Crossref] [PubMed]
26. Wojnarski CM, Roselli EE, Idrees JJ, et al. Machine-learning phenotypic classification of bicuspid aortopathy. J Thorac Cardiovasc Surg 2018;155:461-469.e4. [Crossref] [PubMed]
27. Della Corte A, Bancone C, Quarto C, et al. Predictors of ascending aortic dilatation with bicuspid aortic valve: a wide spectrum of disease expression. Eur J Cardiothorac Surg 2007;31:397-404; discussion 404-5. [Crossref] [PubMed]
28. Michelena HI, Della Corte A, Evangelista A, et al. International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes. Eur J Cardiothorac Surg 2021;60:448-76. [Crossref] [PubMed]
29. Berger T, Kreibich M, Rylski B, et al. The 3-step approach for the treatment of multisegmental thoraco-abdominal aortic pathologies. Interact Cardiovasc Thorac Surg 2021;33:269-75. [Crossref] [PubMed]
30. Berger T, Weiss G, Voetsch A, et al. Multicentre experience with two frozen elephant trunk prostheses in the treatment of acute aortic dissection†. Eur J Cardiothorac Surg 2019;56:572-8. [Crossref] [PubMed]
31. Berger T, Kreibich M, Mueller F, et al. Risk factors for stroke after total aortic arch replacement using the frozen elephant trunk technique. Interact Cardiovasc Thorac Surg 2022;34:865-71. [Crossref] [PubMed]
32. Sakamoto K, Shimamoto T, Esaki J, et al. Comparison of open and hybrid endovascular repair for aortic arch: a multi-centre study of 1052 adult patients. Eur J Cardiothorac Surg 2024;66:ezae377. [Crossref] [PubMed]
33. Settepani F, Cappai A, Basciu A, et al. Outcome of open total arch replacement in the modern era. J Vasc Surg 2016;63:537-45. [Crossref] [PubMed]
34. Berger T, Kreibich M, Mueller F, et al. The frozen elephant trunk technique for aortic dissection is safe after previous aortic repair. Eur J Cardiothorac Surg 2021;59:130-6. [Crossref] [PubMed]
35. Tenorio ER, Oderich GS, Kölbel T, et al. Multicenter global early feasibility study to evaluate total endovascular arch repair using three-vessel inner branch stent-grafts for aneurysms and dissections. J Vasc Surg 2021;74:1055-1065.e4. [Crossref] [PubMed]