Figure 1.

Illustration of total aortic arch replacement using the Thoraflex Hybrid Plexus (branched) device, manufactured by Terumo Aortic. (A) An extensive aneurysm spans the ascending aorta, aortic arch, and descending thoracic aorta. (B) The right axillary artery is cannulated, and antegrade cerebral perfusion is aided by inserting a balloon perfusion catheter into the left common carotid artery. The aorta is transected at the sinotubular junction and distal to the left subclavian artery. A guidewire is advanced retrograde via the femoral artery and manually retrieved through the transected descending thoracic aorta. The Thoraflex device is threaded onto the guidewire and advanced antegrade into the descending thoracic aorta. (C) After the endograft is deployed, the delivery system is removed. Incorporating the device collar and residual native aorta completes the distal anastomosis, which secures the endograft portion and prevents migration. The brachiocephalic arteries are incorporated into the non-stented graft portion of the device with graft bypass using the branched Plexus model or by island reattachment using the Ante-Flo model (inset). The proximal anastomosis is completed at the level of the sinotubular junction unless additional patient-specific repair is needed. Supplemental perfusion is provided through a side branch while the brachiocephalic arteries are incorporated into the repair. (D) Although the total arch replacement repair (stage 1) is complete, additional repair to address the descending thoracic aorta is needed. Inset: In some patients, definitive repair in a single stage is possible. (E) After a variable period of recovery, an endovascular completion (stage 2) repair is performed. Commonly, one or more stent-grafts are advanced retrograde via the femoral artery. Stent-grafts are recommended to overlap the Thoraflex by 4 cm whenever possible. Used with permission of Baylor College of Medicine.