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Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS) https://esvs.org/wp-content/uploads/2... #AorticArch #VascularSurgery #CardiacSurgery #Aneurysm #Dissection #Endovascular #OpenSurgery #HybridRepair #CTAngiography #TEVAR #FET #MultidisciplinaryTeam #ComplexCare The aortic arch, distributing blood to the head and arms, is a critical site prone to serious pathologies like aneurysms (bulging) and dissections (tearing). Standardised terminology and classification (Ishimaru zones, Stanford types A/B/non-A non-B, acute/subacute/chronic phases) are vital for communication. Dissections are complicated by rapid expansion, rupture, or malperfusion. Less common issues include intramural hematoma (IMH), penetrating aortic ulcer (PAU), thrombus, aberrant anatomy (subclavian artery, Comorhals diverticulum), trauma, infection, and inflammatory conditions like Giant cell and Takayasu's aortitis. Diagnosis and planning rely heavily on advanced imaging: CTA is first-line for speed and 3D detail, MRI is gold standard for dynamic flow visibility, and ultrasound (TOE-E, IVUS) offers real-time, high-resolution views. A comprehensive workup assesses the whole system, including cardiac function, coronaries, branch vessels, and crucially, cerebral cross-flow via the circle of Willis. Decision-making absolutely requires a dedicated multidisciplinary aortic team, ideally in a high-volume, specialised centre with both open and endovascular expertise. Treatment options include traditional open repair (sometimes with standard or frozen elephant trunk - FET), hybrid debranching plus T-VAR, and complex total endovascular arch repair using branched or fenestrated grafts. Technique selection depends on patient anatomy, pathology, risk, and underlying conditions like connective tissue disorders. Protecting the brain and spinal cord during procedures is paramount, requiring sophisticated monitoring (NIRS, electrophysiological, CSF drainage). While innovation expands options, especially endovascular, high stroke risk and uncertain long-term durability, particularly in connective tissue disease or with non-standard techniques like chimneys, remain challenges. Evidence for newer techniques is often limited to expert consensus (Class C) due to rarity and rapid technological evolution, highlighting the need for registries and collaborative research.