Fenestrated and branched thoracic endovascular aortic repair (f/b-TEVAR) of the aortic arch is a viable approach in patients unsuitable for open repair. The aim is to summarise the published results of manufactured f/b-TEVAR devices for partial and total repair of the aortic arch, and to compare fenestrated vs. branched configurations. PubMed, Scopus and The Cochrane Library were searched for articles (2018 - 2021) about patients with elective/urgent/emergent aortic requiring a proximal landing zone in the aortic arch (zone 0 - 1 - 2) and treated by f/b-TEVAR. Systematic review and meta-analysis were performed according to the PRISMA guidelines. Open repair, supra-aortic trunk (SAT) debranching + standard TEVAR, and in situ/physician modified/parallel grafts were excluded. Primary outcomes were technical success and 30 day mortality. Secondary outcomes were 30 day major adverse events, and overall survival and procedure related endpoints during follow up. Out of 458 articles screened, 18 articles involving 571 patients were selected. Indications for intervention were chronic dissections (50.1%), degenerative aneurysms (39.6%), penetrating aortic ulcers (7.4%), and pseudoaneurysms (2%). f-TEVAR, b-TEVAR, and f + b-TEVAR were used in 38.4%, 54.1%, and 7.5% of patients, respectively. Overall, technical success was 95.9% (95% confidence interval [CI] 0.93 - 0.97; I² = 0%; p for heterogeneity (Het) = .77) and 30 day mortality was 6.7% (95% CI 0.05 - 0.09; I² = 0%; p Het = .66). No statistical differences were found comparing fenestrated vs. branched endografts, except for a higher rate of type I - III endoleaks in f-TEVAR (9.8% vs 2.6%; p = .034). Overall survival rate and freedom from aortic related death at the one year follow up ranged between 82 - 96.4% and 94 - 94.7%, respectively. Thirteen and five studies were considered at moderate and high risk of bias, respectively. f/b-TEVAR for the treatment of the aortic arch, nowadays show, according to experience in dedicated centres, a satisfactory level of technical success together with progressive lowered load in terms of early mortality. There are of several limitations, and further studies are needed to reach clearer conclusions.

Background/Objectives: Carbon dioxide digital-subtraction angiography (CO₂-DSA) is an increasingly adopted technique in endovascular aortic repair (EVAR) and fenestrated/branched EVAR (F/B-EVAR); it is used to reduce the amount of iodinate contrast medium (ICM) and prevent postoperative renal function worsening (PO-RFW). Our aim is to report results from the literature on EVAR and F/B-EVAR procedures using CO₂-DSA, together with wider applications in aortic endovascular treatment. Methods: We performed a literature review by searching electronic databases for published data on CO₂-DSA during EVAR and F/B-EVAR procedures. The endpoints were postoperative renal function worsening (PO-RFW) and efficacy of intraoperative arterial visualization. Further, applications of CO₂ for thoracic endovascular aortic repair (TEVAR) were described. Results: Seventeen studies reporting results on CO₂-DSA in EVAR (644 patients) were retrieved. Overall, 372 (58%) procedures were performed with CO₂ alone, and 272 (42%) were performed with CO₂+ICM. Eight studies analyzed the effect of CO₂-DSA angiography on PO-RFW; four studies showed a significantly lower rate of PO-RFW compared to ICM. Five studies (153 patients) analyzed intraoperative arterial visualization with CO₂-DSA; renal and hypogastric arteries were effectively visualized in 69% and 99% of cases, respectively. The use of CO₂-DSA in F/B-EVAR has not been widely investigated. The largest series reported that PO-RFW was lower in the CO₂ vs. ICM group. Conclusions: Carbon dioxide is widely applied in modern aortic endovascular treatment. CO₂-DSA for EVAR and F/B-EVAR is an efficient technique for reducing PO-RFW while allowing acceptable arterial intraoperative visualization.

Paravisceral aortic lesions present significant challenges for endovascular treatment. This retrospective analysis of consecutively treated patients from April 2017 to June 2021 aimed to analyse the outcome of primary intra-operative embolisation of aortic complicated pseudoaneurysms and gutter channels during parallel graft (PG) repair of paravisceral symptomatic aortic pseudoaneurysms. Patients with symptomatic pseudoaneurysms of the paravisceral aorta treated with PGs using chimney or periscope configurations were included. Thoracic endografts were positioned to exclude the aortic lesions. Coil embolisation of both the lesions and gutter channels was performed after graft deployment and prior to ballooning of the stent grafts. The primary endpoints were technical success (defined as exclusion of the pseudoaneurysm, target visceral vessel [TVV] patency, absence of gutter endoleaks) and clinical success (technical success + resolution of symptoms + absence of major adverse events) at 30 days. Secondary endpoints included overall survival, TVV patency, gutter endoleaks, and freedom from re-interventions during follow up. Six patients (four women) were treated for pseudoaneurysm rupture (three cases) and symptomatic aortic pseudoaneurysm (three cases) of the paravisceral aorta. The patients' anatomies were unsuitable for off the shelf devices and patients were all deemed to be at prohibitive surgical risk. A total of 15 TVVs were revascularised (comprising three coeliac arteries, five superior mesenteric arteries, and seven renal arteries) using 10 chimney and five periscope PGs. One coeliac artery was occluded. Seventy coils were deployed to embolise both the aortic ruptures and gutter channels. Both technical and clinical success rates were 100%. The median follow up was 17 months (IQR 5, 35), during which time three patients died due to non-aortic related causes. One coeliac artery (6%) was occluded, and no endoleak evidence was found. Primary intra-operative embolisation during parallel graft endovascular repair of paravisceral symptomatic aortic pseudoaneurysms may be both safe and effective in excluding the pseudoaneurysm when other options are unavailable.