CX Aortic Vienna: Global experts share knowledge on aortic arch and thoracoabdominal techniques

Clockwise from top left: Roger Greenhalgh (London, UK); Stéphan Haulon (Paris, France); Roberta Chiesa (Milan, Italy); George Matalanis (Victoria, Australia); and Gustavo Oderich (Houston, USA).

The ever-changing subject of aortic arch and thoracoabdominal treatment was addressed at CX Aortic Vienna 2021 (5–7 October, broadcast), with input from speakers and audience participation from across the globe. Edited cases and presentations from The Netherlands, France, Australia, the USA, the UK, China and Italy outlined the latest developments in the space. The session was also broadcast as part of the China Endovascular Course (CEC).

All sessions are available to view on demand. Click here to register and access the recordings.

One such global demonstration came from Michael Jacobs (Maastricht, The Netherlands), who presented an edited case of the “clamshell” incision technique to perform open ascending, arch and descending aortic repair.  

Following this presentation, moderator Stéphan Haulon (Paris, France) noted that pericardium grafts made from bovine materials—such as the one seen in Jacobs’ presentation—have been a “game-changer” and are now the number one choice in infectious cases. Jacobs agreed, adding that these materials appear to be far more infection-resistant than those previously used. 

Registrants can view Jacobs’ presentation on demand here. 

A later edited case saw George Matalanis (Victoria, Australia) share a branch-first, computed tomography (CT) total arch replacement—claiming that the “beauty” of the procedure is that it is adaptable to many different pathologies, both acute and chronic. A topic that was explored in depth during the previous day’s programme at CX Aortic Vienna also resurfaced, as Matalanis noted that he staged the procedure to improve precision and reduce spinal cord ischaemia (SCI) risks.  

Registrants can view Matalanis’ presentation on demand here. 

An edited case from Gustavo Oderich (Houston, USA), who demonstrated a left subclavian artery (LSA) branch reconstruction using an endovascular approach, also featured in this session. He noted that selective angiography following the procedure confirmed the LSA was widely patent, but also revealed partial coverage of the innominate artery—leading him to realign the scallop using a balloon-expandable stent.  

Discussing this, Haulon stated that, if the cone-beam CT had not been performed and revealed this potential complication, the patient may have later had a stroke, further noting that this was “an important message”. Oderich concurred, adding that postprocedural technical assessments are “critical”, while the session’s anchor, Roger Greenhalgh (London, UK), conveyed that the case highlighted a “golden rule” of vascular surgery, which is to always check results on the table.  

Registrants can view Oderich’s presentation on demand here. 

Elsewhere, Chang Shu (Beijing, China) presented the HENDO approach to aortic arch repair, which combines hybrid, endovascular and open surgical techniques. Shu shared insight on surgical practice at his centre in China as well, stating that younger vascular surgeons are often trained in open surgery first, before moving on to endovascular techniques later.   

Registrants can view Shu’s presentation on demand here.

Stéphan Haulon demonstrated a “very challenging” fenestrated endovascular aneurysm repair (FEVAR) case and also gave a presentation on percutaneous three-branch arch endografting. Moderator Oderich noted that he has performed just one such case and that the technique is an example of the evolution of the subject over the last 20 years. The area is where industry needs to focus going forward, he commented.

Registrants can view Haulon’s edited case on demand here and his presentation on demand here.

In another edited case, Michele Antonello (Padua, Italy) spoke on the geometrical determinants of target vessel instability in FEVAR, concluding that the sizing and planning of FEVAR should be performed in order to maintain a bridging length <5mm. He added that new-generation bridging stents have showed a higher flare capability in his experience, and, even if they are not associated with clinical outcomes, show promise.

Moderator Kölbel highlighted that Oderich is the “expert” on the topic, having introduced the term alongside Tara Mastracci (London, UK), which “really was a change in describing outcomes of branched FEVAR and branched EVAR (BEVAR)”.

Oderich asked Antonello to comment on the rates of renal artery occlusion in his experience. “If we have some very tortuous anatomy of the renal arteries, we switch to renal branches,” he replied, stating his belief that the technology “could be better”.

Registrants can view Antonello’s edited case on demand here.

Giovanni Rossi (Lecco, Italy) presented a case on the PETTICOAT distal extended endovascular aortic repair concept, which he summarised as “a modified technique to improve false lumen remodelling in acute type B aortic dissection”. He noted that PETTICOAT is now his primary technique for all dissection but remains “a work in progress”.

Registrants can view Rossi’s edited case on demand here.

An edited case by Jan Heyligers (Tilburg, The Netherlands) demonstrated the use of Cydar for BEVAR. He described the technology as a “step forward” not only in complex cases but in endovascular approaches in general. Oderich commented that, at his centre in Houston, the team is trying to decide whether or not to adopt Cydar technology. They already have a system with fusion and so Oderich was keen to find out if there are any added benefits. Heyligers emphasised the accuracy of the technology, its ability to reduce procedure time, and also the fact that it comes with software updates.

Registrants can view Heyliger’s edited case on demand here.

In the final presentation of the session, Alessandro Castiglioni presented his preferred technology for chronic arch and descending aorta dissection with the “debranch first” technique. This “seems to be an attractive solution to reduce time of distal body circulatory arrest (15–20 minutes), SCI and postoperative paraplegia,” he concluded. Picking up on a common theme during CX Aortic Vienna, the speaker noted that collaboration between cardiac and vascular surgeons is “very good” at his centre, after which Oderich remarked that Castiglioni’s case “demonstrates what you can achieve in an aortic centre”.

Registrants can view Castiglioni’s presentation on demand here.


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