Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the EACTS and the ESVS

Introduction

The last decade has substantially broadened treatment options for patients with thoracic aortic pathology involving the aortic arch. Traditionally, treatment of aortic arch pathology was a domain of open cardiac surgery. The advent of combined vascular and endovascular procedures opened a new field thereby enabling treatment in previously operated on and in less fit patients. As a subsequent technological leap, branched arch stent grafts became available and are currently gaining acceptance in the community. Also, open surgery has substantially improved, and the increased use of right subclavian artery cannulation and selective antegrade cerebral perfusion (SACP) at warmer lower body circulatory arrest times together with improved monitoring of organ function has substantially contributed to excellent results in these still major operations. Still, neurological complications remain a major concern of all procedures addressing aortic arch pathology irrespective if open surgery or endovascular repair. The reduction of neurological complications to a minimum will be one of the major tasks of the future.

Cross linking between cardiac and vascular surgery has amplified knowledge. Interestingly enough, although dividing cardiac and vascular surgery into separate units was popular for a time, in many institutions they are being combined again to create aortic centres, a trend which should be interpreted as a plea to work together without creating borders between specialties.

Our hope is that, in the future, treatment portfolios will be designed by a single group of people working together to understand the natural course of the disease where physicians are doing the right things when it comes to treatment and the entire aortic team follows an anticipative strategy to remain ahead of the disease process.

The purpose of this combined effort of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) was to develop an expert consensus document covering all aspects of aortic arch disease and to provide the community with a pragmatic guide to understand the natural history of the various disease processes, to aid in indicating treatment and to provide support in choosing the right treatment modality in the right patient at the right point in time. Finally, this document aims to harmonize terminology in acute and chronic proximal thoracic aortic pathology.