Total endovascular arch repair in Bologna JTCVS represents an early but important phase of complex aortic arch treatment delivered through a fully endovascular approach. This initial experience focuses on team formation, procedural selection, and early outcomes in a high-volume academic center.
By leveraging advanced imaging, hybrid operating suites, and structured arch-first strategies, the Bologna JTCVS team aims to reduce cerebral and spinal ischemia while maintaining technical success and acceptable perioperative bleeding.
Initial Cohort Overview
During the first implementation phase, the group reported on patient demographics, procedure types, and early safety metrics to establish benchmarks for future series.
| Parameter | Details | Metric | Value |
|---|---|---|---|
| Institution | University Hospital Bologna, Cardiac Surgery | Reporting Period | First 24 months |
| Indication | Type A, B, or complex arch pathologies | Total Patients | 42 |
| Approach | Total endovascular via transfemoral access | Provisional Compatibility | Fully endovascular arch technique |
| Access Strategy | Bilateral common femoral + optional iliac extension | Device Utilization | Branch and chimney grafts |
| Neuroprotection | Selective antegrade cerebral perfusion via arch branches | ICU Stay (median) | 1.5 days |
| 30-Day Outcomes | Mortality, stroke, spinal cord ischemia, reintervention | Early Mortality | 4.8% |
| Arch Completeness | Endovascular cover of arch vessels and descending start | Technical Success | 97.6% |
Hybrid Suite and Imaging Protocol
Operating Room Configuration
Bologna JTCVS utilizes a hybrid operating room with flat-panel imaging, 320-detector CT integration, and advanced roadmapping software to plan fenestrations and optimize landing zones before skin incision.
Precise Pre-Planning Workflow
Multiplanar reconstruction and computational flow analysis guide device selection, reduce procedure time, and help anticipate anatomical challenges such as great vessel tortuosity and branch dominance.
Surgical Technique and Arch-First Strategy
The team employs an arch-first strategy with antegrade perfusion through selected arch vessels, allowing staged deployment of the descending thoracic aorta while maintaining cerebral and myocardial protection.
In selected patients, controlled multicannulation enables simultaneous monitoring of bilateral perfusion, minimizing reliance on hypothermic circulatory arrest and reducing neurologic risk.
Early Clinical Results and Safety Profile
Initial results demonstrate acceptable perioperative bleeding, low transfusion rates, and limited need for postoperative ECMO, reflecting a learning-curve advantage from prior open arch experience.
Stroke and spinal cord complication rates remain favorable compared to historical controls, supported by tailored perfusion strategies, careful graft oversizing, and strict postoperative neurologic monitoring.
Future Directions and Program Evolution
The Bologna JTCVS initiative plans to expand the cohort, refine endovascular graft design for complex arch anatomy, and integrate longitudinal follow-up to assess durability, quality of life, and cost-effectiveness.
- Standardize patient selection based on imaging and hemodynamic criteria
- Implement structured training and simulation for team coordination
- Adopt consistent neurophysiologic monitoring algorithms
- Track long-term reintervention and survival with national registry linkage
- Develop hybrid education programs to share early experience across centers
FAQ
Reader questions
How does Bologna JTCVS define total endovascular arch repair in this initial experience?
Total endovascular arch repair refers to complete endovascular coverage of the aortic arch and descending aorta using branch and chimney grafts, performed without formal sternotomy or circulatory arrest.
What patient selection criteria were applied during the initial phase?
Patients with Type A dissections, complex arch aneurysms, or debakey Type B pathologies requiring extensive arch involvement were considered, provided access anatomy and visceral perfusion territories were favorable.
What neuroprotection strategies were used during the procedures?
The team favored selective antegrade cerebral perfusion via arch branches, with adjuncts such as mild therapeutic hypothermia and near-infrared spectroscopy to guide perfusion adequacy and minimize ischemic burden.
What are the key learning points identified by the Bologna team?
Early identification of landing zone challenges, meticulous device sizing, structured teamwork, and standardized postoperative monitoring protocols are essential to reduce conversion risk and improve long-term outcomes.