Strategic evolutions in the treatment of aneurysms involving the posterior aortic arch

Thoracic aortic stentgrafts is now highly recommended when anatomically feasible, as it induces less morbidity and mortality and postoperative paraplegia than open repair in thoracic aortic disease. The posterior aortic arch, when affected by aneurysmal lesions, is prone to proximal endoprosthesis apposition defects. Therefore, practitioners aim to achieve a better sealing zone by transposing supra-aortic trunks or using new devices dedicated to the aortic arch. Another strategy consists in positioning an elephant trunk anteriorly from the arch into the descending thoracic aorta, providing an excellent sealing zone for a thoracic stentgraft introduced via the femoral route. This strategy most often allows to treat thoracic aortic diseases with endovascular devices. If necessary, completion of distal repair in a second or even third surgical phase can be performed to limit the risk of postoperative paraplegia.