Duplex ultrasound-based comparative analysis of inner branch orientation for the left common carotid artery following triple-branch arch endovascular repair.

Abstract

Objective: The purpose of this study was to evaluate left common carotid artery (LCCA) perfusion using duplex ultrasound (DUS) examination after endovascular repair of the aortic arch (endoarch) with a triple-branch arch device, featuring either an anterograde or retrograde inner branch configuration for the LCCA.

Methods: Patients who underwent branched endoarch repair from May 2020 to February 2025 were identified using a prospectively maintained electronic database at a single tertiary care hospital. Inclusion criteria included implantation of the triple-branch arch device (Cook Medical) with an anterograde inner branch for the brachiocephalic trunk, an anterograde or retrograde inner branch for the LCCA, and a retrograde branch for the left subclavian artery. Exclusion criteria included no follow-up and postoperative DUS examination. Patient demographics, comorbidities, indication for the procedure, procedural details, and outcomes were recorded. The cohort was dichotomized based on LCCA branch orientation. The primary outcomes were to define postoperative DUS-based perfusion metrics of the bilateral carotid arteries and to compare them based on the orientation of the LCCA branch. The right CCA (RCCA) served as a control, because it featured only an anterograde branch for the brachiocephalic trunk. The secondary outcomes were to compare inner branch primary patency, stroke-related outcomes, reintervention, and mortality.

Results: A total of 74 patients underwent endoarch repair with the triple-branch arch device during the study period, of whom 39 met the study inclusion criteria, with 18 (46%) anterograde and 21 (54%) retrograde inner branches of the LCCA. Most patients were male (74%) with a median age of 72 years. There was a high incidence of hypertension (90%) and dyslipidemia (59%). The indication for repair was a degenerative (51%) or chronic postdissection (49%) aortic arch aneurysm. A totally percutaneous approach for procedural access occurred in 71% of the retrograde group (vs 17% anterograde). There was a decreased median operating time for LCCA retrograde branch of 160 minutes (vs 218 minutes anterograde). Thirty-day stroke was 5% (n = 2, both anterograde), with no mortality. Postoperative DUS examination demonstrated similar perfusion metrics between the experimental LCCA and the control RCCA, regardless of the orientation of the LCCA inner branch. In the retrograde group, both the RCCA and LCCA featured predominantly monophasic (62%) and triphasic (31%) waveforms; the median peak systolic velocity, end-diastolic velocity, and acceleration time were 64 to 68 cm/s, 17 to 21 cm/s, and 56 to 65 ms, respectively. Midterm outcomes (median follow-up, 11 months) were notable for one death, without events of stroke or target vessel-related reinterventions.

Conclusions: In endoarch repair with the triple-branch device, inner branch orientation yields no significant difference in DUS-based perfusion metrics of both carotid arteries. In the retrograde orientation of the LCCA inner branch, there was decreased operative time with increased rates of a totally percutaneous approach, without an increased incidence of stroke or reintervention. This retrospective study further supports the device modification from the anterograde to retrograde orientation of the LCCA inner branch in favorable anatomies.