Early Multicentre Experience with Exclusively Retrograde Multiple Branched Endovascular Aortic Arch Repair

Objective: To report initial experience using endografts with exclusively retrograde inner branches for endovascular aortic arch repair. Methods: A retrospective review of endovascular aortic arch repairs using custom made endografts exclusively integrating retrograde inner branches (Cook Medical, Brisbane, Australia) was conducted across seven tertiary centres (June 2022 and December 2024). Primary endpoints included technical success and peri-operative morbidity and mortality. All consecutive patients were included. Results are presented as numbers or median (interquartile range [IQR]). Results: Twenty-one patients (nine women; median age, 72 years; IQR 66, 77 years; 13 with chronic dissection) were treated using 19 endografts with three branches and two endografts with two branches, totalling 61 retrograde inner branches. All target vessels were successfully bridged, mostly from femoral access (n = 18) but three required axillary (n = 2) or carotid (n = 1) accesses. Technical success was achieved in 18 patients; one patient experienced irreversible cardiac arrest, and two others had small residual type Ia endoleaks. Two patients required an iliac endoconduit for vessel rupture. These two patients were the only ones who developed a post-operative ischaemic stroke. One of them recovered fully in hospital, whereas the other patient died due to extensive renovisceral embolisation. No other peri-operative deaths were observed (two of 21 patients). Three patients presented with evidence of aortic graft stenosis in the arch that was corrected either during surgery or during early follow up. The latter, after new onset congestive heart failure, was reversed by correction of the aortic graft stenosis. During a median follow up of 10 months (IQR 4, 13 months), one patient required false lumen embolisation due to type Ic endoleak, and two patients died due to distal aneurysm rupture and respiratory failure. Conclusion: Endovascular aortic arch repair with exclusively retrograde inner branches is feasible with acceptable technical success and no branch related re-intervention. Aortic graft stenosis in the arch is a concern with this design that requires further investigation. This design can potentially overcome the need for large bore upper extremity or carotid access, but larger series with longer follow up are needed to demonstrate safety, efficacy, and durability.