Background: The anatomical complexity of the aortic arch poses significant challenges to its repair, particularly in high-risk patients. The introduction of branched endografts, specifically designed to overcome these challenges, has revolutionized this field as demonstrated in the present case-report.   Report: A 60-year-old male, with a prior history of smoking and neurosyphilis, was referenced to our outpatient clinic due to a CT finding of a 66mm aortic arch aneurysm with complex anatomical features, including a short brachiocephalic trunk and narrow iliac arteries. Thus, a staged hybrid approach was meticulously planned. The patient was initially submitted to a left carotid-subclavian bypass, followed by a right subclavian-carotid bypass. Later, an endoconduit was constructed using two GORE-Viabahn® stent grafts (11x100mm), deployed in the left common and external iliac arteries, facilitating subsequent TEVAR. Finally, the aneurysm was excluded using a custom-made Terumo-Relay® double inner-branched endograft (46x32x270mm) deployed in zone 0, with two inner branches for the brachiocephalic trunk (BCT)/right subclavian artery (RSA) and left common carotid artery (LCCA). The inner branches were catheterized via trans-carotid (left) and trans-axillary (right) accesses. An iliac extension GORE-Excluder® (16x12x100mm) to the BCT/RSA and a GORE-Viabahn® stent graft (7x75mm) to the LCCA were deployed. An additional extension endograft (34x30x150mm) was deployed to complete distal exclusion. The left subclavian artery was subsequently occluded using a vascular plug. Postoperatively, the patient experienced a minor posterior circulation stroke, with full recovery within two weeks. Six-month follow-up imaging showed patency of the endografts with complete exclusion of the aneurysm and no evidence of endoleaks. The patient remained asymptomatic, with no further vascular or neurological events.   Conclusion: This case highlights the feasibility of a staged hybrid approach for complex aortic arch aneurysms in patients with challenging anatomy. The use of a custom-made endograft and careful preoperative planning proved critical to the success of the procedure.

INTRODUCTION: Endovascular approaches have emerged as promising alternatives for treating aortic arch pathology, particularly in high-risk patients. This review provides a comprehensive analysis of total endovascular aortic arch reconstruction, focusing on Parallel Graft Techniques (PGTs) and Custom-Made Devices (CMDs). METHODS: PubMed and Scopus were searched to conduct a comprehensive review comparing the technical aspects, clinical outcomes, strengths, and limitations of PGTs and CMDs. Only studies reporting on total endovascular aortic aneurysm repair were considered. Studies with fewer than five patients, published in a language other than Portuguese, English, or Spanish, and reporting hybrid/open procedures or partial aortic arch reconstructions were excluded. Findings were summarised descriptively. RESULTS: A total of 38 studies comprising 871 patients were included (214 in PGT and 657 in the CMD group). Technical success rates were high in both groups, mostly ranging from 80%80% to 100%100%. No clear superiority was observed between the two approaches for thirty-day, aorta-related, or overall mortality. However, stroke and spinal cord ischaemia (SCI) rates appeared higher in the CMD group, ranging from 0 to 42.9%42.9% and 0 to 9.1%9.1% respectively. The occurrence of type I and III endoleaks was higher in the PGT group (0-45.5% versus 0-32.4%), though this did not translate into a clear difference in reintervention rates. During follow-up, high target vessel patency rates were observed in both groups, typically exceeding 95%95% . CONCLUSION: PGTs appear to have non-inferior outcomes in terms of stroke rate and in-hospital and overall mortality. Although the occurrence of type I/III endoleaks remains higher in PGTs, this does not seem to affect reintervention rates. Thus, PGTs should be considered a viable option for treating complex aortic arch pathology, particularly in fragile patients, those with adverse anatomy, or in emergent situations. Large-volume prospective studies directly comparing these two techniques are currently warranted.

Abstract Introduction: Endovascular approaches have emerged as promising alternatives for treating aortic arch pathology, particularly in high-risk patients. This review provides a comprehensive analysis of total endovascular aortic arch reconstruction, focusing on Parallel Graft Techniques (PGTs) and Custom-Made Devices (CMDs). Methods: PubMed and Scopus were searched to conduct a comprehensive review comparing the technical aspects, clinical outcomes, strengths, and limitations of PGTs and CMDs. Only studies reporting on total endovascular aortic aneurysm repair were considered. Studies with fewer than five patients, published in a language other than Portuguese, English, or Spanish, and reporting hybrid/open procedures or partial aortic arch reconstructions were excluded. Findings were summarised descriptively. Results: A total of 38 studies comprising 871 patients were included (214 in PGT and 657 in the CMD group). Technical success rates were high in both groups, mostly ranging from 80% to 100%. No clear superiority was observed between the two approaches for thirty-day, aorta-related, or overall mortality. However, stroke and spinal cord ischaemia (SCI) rates appeared higher in the CMD group, ranging from 0 to 42.9% and 0 to 9.1%, respectively. The occurrence of type I and III endoleaks was higher in the PGT group (0-45.5% versus 0-32.4%), though this did not translate into a clear difference in reintervention rates. During follow-up, high target vessel patency rates were observed in both groups, typically exceeding 95%. Conclusion: PGTs appear to have non-inferior outcomes in terms of stroke rate and in-hospital and overall mortality. Although the occurrence of type I/III endoleaks remains higher in PGTs, this does not seem to affect reintervention rates. Thus, PGTs should be considered a viable option for treating complex aortic arch pathology, particularly in fragile patients, those with adverse anatomy, or in emergent situations. Large-volume prospective studies directly comparing these two techniques are currently warranted.