L-R: Dittmar Böckler, Eric Verhoeven and Hence Verhagen
“Centralisation and interdisciplinary teams—they are the keys,” Dittmar Böckler (University Hospital Heidelberg, Heidelberg, Germany) concluded during a roundtable discussion at the 2024 Charing Cross (CX) International Symposium (23–25 April, London, UK) on the future of aortic arch treatment.
Böckler had been speaking with Eric Verhoeven (General Hospital Nuremberg, Paracelsus Medical University, Nuremberg, Germany) and Hence Verhagen (Erasmus Medical Center, Rotterdam, The Netherlands) at the CX Live Studio to hear their thoughts on what the future of aortic arch treatment, and specifically the future of endovascular therapy in the arch, looks like.
“We know that for decades open surgery was the standard,” Böckler began, “but now we have so many other options to treat our patients.” Against this backdrop, the CX co-chair was keen to hear the experts’ opinions on the new therapeutic options that are available.
Verhoeven set the scene by acknowledging the challenges of treating the arch via endovascular means. “I think we are boarding the most difficult part [of the aorta] for endovascular treatment, but we are at the beginning, which means the future is probably bright,” he said with cautious optimism. However, while noting that progress has been made over the last couple of years, Verhoeven did acknowledge that there is “room for improvement” regarding devices.
Verhagen echoed this thought, adding that endovascular treatment of the arch is still “experimental”. He expressed a belief that, in the not-so-distant future, endovascular “will take over” but that the field is “not there yet,” citing some significant issues that need to be resolved.
The conversation then moved to the evidence base for endovascular therapy, with Verhoeven and Verhagen sharing some insights from their daily practice.
Verhoeven opined that technically, endovascular treatment of the arch is “not that difficult” thanks in large part to branched devices being “relatively forgiving” and the technique being well known among specialists. However, he also pointed out that there remains a “substantial” risk of stroke.
Adding to that, Verhagen stated that patient selection is key. He cited promising results from the last two years that he believes are likely to do with good technique and improved patient selection. “We’re just starting to learn about which patient is suitable for this technique at the moment, and which is not,” he said.
With various endovascular solutions available, Böckler then asked whether there is one best way to treat arch disease, or whether there is a need for multiple options on the market—customised and off the shelf, branched and fenestrated.
Verhoeven emphasised the importance of having off-the-shelf devices available for arch treatment, commenting that there is “no doubt” more will be on offer soon. “[This] is a plea to the companies to provide us with grafts that are readily available because many of the pathologies deserve early treatment,” he said.
Verhagen agreed, adding that an off-the-shelf device is “easier for everyone” than a custom-made device. However, he did express uncertainty about whether it would be possible to create a device that fits at least 80% of patients.
Verhagen then highlighted something that is currently lacking with regard to endovascular devices for arch treatment. “We haven’t figured out what the materials of the branches should be,” he pointed out. “We all know that the strokes don’t stop at 30 days, they tend to keep on coming, and that may have something to do with either a suboptimal anticoagulation schedule [or] it may have something to do with the fabric of the branches—we haven’t figured it out yet.”
Having outlined the importance of learning more about patient selection and graft design, the conversation then turned to what an aortic arch treatment service should look like. “Do we need to centralise [it]? Do we need high-volume centres? Who should do these kinds of difficult and challenging procedures for our patients?” Böckler asked.
Verhoeven underscored the importance of a multidisciplinary approach. “It speaks for itself that we cannot do this without involving the cardiac surgeons,” he said, “which automatically means that this should be done only in centres where cardiac surgery is present and also cooperating with vascular surgery very well—I think that’s imperative.”
In addition, Verhoeven commented that “centralisation of these procedures is a must” in order to have a “neutral and objective evaluation of the patients to see whether they will get an open repair or any type of endovascular repair”.
Verhagen did express some caution, based on his own experience. He remarked that centralisation in The Netherlands is proving to be a “painful process” and that he is unsure whether it will succeed in the long term.
Nevertheless, he did agree with Verhoeven overall that “close cooperation with your cardiothoracic surgeons, maybe the radiologists, the cardiologists, the interventional cardiologists” is key and that a “fairly big team looking after a fairly small [number] of patients” necessitates centralisation as a key element of any successful aortic arch treatment programme.
