Preoperative planning for endovascular aortic arch repair

Background: Endovascular repair of aortic arch pathology is an evolving treatment option for selected patients, particularly those at high or prohibitive risk for conventional open arch replacement. However, the complex three-dimensional anatomy of the aortic arch, high pulsatile flow, proximity of the supra-aortic vessels, and the need for durable proximal and distal sealing make these procedures technically demanding. Careful patient selection, high-quality imaging, and systematic preoperative planning are therefore essential determinants of procedural success.
Methods: This article presents a structured approach to preoperative planning for endovascular aortic arch repair. The planning process includes confirmation of guideline-based indications for intervention, operative risk assessment, selection between open, hybrid, and total endovascular strategies, detailed computed tomography angiography analysis, three-dimensional reconstruction, centerline-based measurements, assessment of landing zones, supra-aortic vessels, access vessels, cerebral collateral circulation, and device-specific anatomical requirements.
Results: Computed tomography angiography remains the principal imaging modality for procedural planning and should include thin-slice acquisition, appropriate contrast opacification, electrocardiogram (ECG)-gated assessment of the ascending aorta and arch, and scan coverage extending from the circle of Willis to the femoral arteries. Systematic image analysis should begin with axial source images before three-dimensional reconstruction, in order to identify thrombus, calcification, shaggy aorta, dissection, intramural hematoma, anatomical variants, and other features relevant to device implantation. Centerline and curved multiplanar reconstruction allow accurate measurements of vessel diameter, length, curvature, landing zones, and supra-aortic vessel orientation. These data guide the selection of debranching, scalloped, fenestrated, or branched endovascular strategies.
Conclusions: Successful endovascular aortic arch repair depends on meticulous preoperative planning, multidisciplinary decision-making, and strict anatomical feasibility assessment. Because current arch endovascular technologies remain anatomically restrictive and device-specific, they should be applied only in carefully selected patients after comprehensive imaging analysis and comparison with available surgical alternatives.