Figura 1. CT angiography imaging.

Figura 2. Aortic diameters: 21 mm and 24 mm (minimum required: >29 mm).

Figura 3. Angiographic sequence. (1) Leak identification. (2) Visualization of the false lumen proxi...

Figura 4. Step-by-step implantation sequence and final angiography.

Figura 5. Post-implantation follow-up CT angiography.

Introduction

Aortic arch repair remains a formidable challenge.

Over recent years, treatment has evolved from hybrid approaches toward dedicated systems that allow for complete repair without cardiopulmonary bypass.

Current guidelines from the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) establish endovascular aortic arch repair as a valid alternative (Class IIb, Level of Evidence B) in patients with favorable anatomy and prohibitive surgical risk3.

Endovascular arch repair — with proximal fixation in the ascending aorta (Ishimaru Zone 0) and branches for the supra-aortic trunks — has emerged as an option for inoperable or high-risk patients, particularly in case of reoperation.

The NEXUS™ endograft (Endospan Ltd., Herzliya, Israel) consists of two modules — one for the arch with an integrated branch for the brachiocephalic trunk, and one for the ascending aorta — enabling Zone 0 proximal fixation while avoiding the need for sternotomy or direct aortic clamping.

The device has received European regulatory approval with encouraging results across multiple series. It is low-profile (20-Fr) and self-expanding, composed of nitinol and polyester.

This article presents the first experience with this device in Argentina, highlighting its technical feasibility and initial outcomes1, 2.

Clinical case

Our purpose was to assess the clinical and radiological outcomes of endograft treatment for chronic type A aortic dissection involving the ascending aorta, aortic arch, and proximal thoracic aorta in a patient deemed inoperable.

In August 2024, we treated a 52-year-old man with a history of type A aortic dissection in 2019, initially managed surgically with ascending aortic replacement using a 0–32-mm porosity Dacron vascular prosthesis. His postoperative course was complicated by mediastinitis requiring surgical debridement, sternal re-closure using the Robicsek technique, and pectoralis muscle flap reconstruction.

Follow-up CTA performed in 2024 demonstrated progressive aneurysmal enlargement distal to the prosthesis, with a chronic dissection flap extending distally from the ascending aorta to the level of the renal artery origins.

Preoperative assessment included high-resolution CTA (Figure 1) to assess arch anatomy and rule out significant aortoiliac disease.

The most common option is hybrid repair through sternotomy reoperation with aorta debranching to a prosthetic conduit to the supraortic vessels followed by endograft implantation. However, this alternative was excluded due to the technical difficulty posed by the short prosthetic segment in the ascending aorta.

CTA images (Figure 1) were used to predict the required fixation and sealing zone lengths and diameters. There was no appropriate fixation zone, as evidenced by the fact that the ascending aorta measured only 21 mm, below the minimum required diameter of 30 mm (Figure 2). Accordingly, a four-stage procedural strategy was planned: (1) debranching; (2) distal ascending aortic stent graft implantation for diameter optimization; (3) aortic arch module deployment; and (4) ascending aorta module deployment.

Surgical technique

1. Supraortic trunk debranching. Under general anesthesia, supraortic trunk revascularization was performed as the first step, redirecting the flow of the supraortic branches (via carotid-carotid bypass and carotid-subclavian bypass) in a bovine arch configuration. Any neurological complications resulting from vessel manipulation were excluded during the subsequent 24-hour observation period.

2. Endograft implantation. Later on, in a hybrid operating room, the endograft was implanted via femoral and brachial access. The total procedure time was 3 hours.

Access was achieved through a surgical cutdown of the right common femoral artery, percutaneous puncture of the right brachial artery with a 7-Fr introducer, and percutaneous puncture of the left common femoral artery.

Percutaneous left femoral venous access was obtained and a temporary transvenous pacemaker was advanced to the right ventricle.

Systemic heparinization was aimed at achieving an ACT ≥300 seconds.

A baseline aortogram was performed via a pigtail catheter introduced through the femoral access, identifying the origin of the brachiocephalic trunk and confirming the chronic dissection secondary to an aorto-aortic prosthesis leak in the ascending aorta (Figure 3).

From the right femoral access, a 400-cm guidewire was advanced and captured using a snare from the right brachial artery, establishing a through-and-through (T-T) rail.

A J-wire and pigtail catheter were then advanced into the left ventricle, followed by exchange for a Safari™ guidewire. A 70×30-mm stent graft was implanted in the ascending aorta, achieving a diameter >30 mm (to optimize landing zone dimensions).

Using bilateral traction on the T-T guidewire, the main body of the endograft was advanced and positioned within the brachiocephalic trunk and aortic arch.

The endoprosthesis main body was deployed, followed by balloon dilation at the level of the brachiocephalic trunk and aortic arch.

The curved module delivery system was then introduced and deployed within the ascending aorta (over the previously implanted stent graft aimed at optimizing the landing zone diameter) under rapid ventricular pacing at 180 bpm to achieve a reduction in cardiac output (Figure 4).

Then, under continued ventricular pacing, simultaneous inflation was performed with a semi-compliant balloon in the brachiocephalic trunk and an elastomeric balloon at the junction between the two prosthetic modules. Final positioning placed the proximal landing zone at arch Zone 0B and the distal landing zone at Zone 4, with the integrated branch seated within the brachiocephalic trunk.

Control angiography via the pigtail catheter revealed endoleak at the proximal ascending aorta. Consequently, a second 43×70-mm ascending aorta module was implanted under rapid pacing, followed by diameter optimization with an elastomeric balloon.

Final angiography confirmed adequate prosthetic apposition, complete aneurysm sac exclusion, and patency of all supra-aortic trunks (Figure 4). Surgical closure of the right femoral access was then performed.

Cerebral perfusion was closely monitored throughout the procedure, with no significant alterations detected. The patient experienced no postoperative complications.

A follow-up CTA was performed at 6 months, showing no evidence of endoleak (Figure 5).

Discussion

Endovascular aortic arch repair has undergone remarkable development driven by the need for less invasive alternatives in patients at high surgical risk or with prior reinterventions. Historically, open arch surgery carried significant morbidity and mortality due to the requirement for cardiopulmonary bypass and deep hypothermic circulatory arrest, prompting the pursuit of endovascular approaches and hybrid techniques.

However, the introduction of dedicated arch devices has transformed this landscape, enabling complete repairs with promising safety outcomes.

Endovascular arch repair is a valid alternative (Class IIb, Level of Evidence B) in patients with favorable anatomy who are at prohibitive surgical risk. The 2024 EACTS/STS Guidelines (3) expanded these recommendations, emphasizing the importance of anatomical patient selection, institutional experience, and long-term imaging surveillance.

Recent systematic reviews4, 5 have solidified the evidence base for total endovascular arch repair, showing that dedicated devices reduce operative time and neurological complications compared with hybrid approaches.

Among dedicated arch devices, the NEXUS™ endograft (Endospan Ltd., Herzliya, Israel) has established itself as a technically attractive option.

Early experiences with this device6 demonstrated technical success rates comparable to traditional hybrid techniques.

Multicenter study results published by D’Onofrio et al. (2022)7 and the Italian INARCHER registry (Antonello et al., 2025)8 report technical success rates exceeding 90%, low endoleak incidence, and overall survival exceeding 85% at three years.

Compared with alternative systems9 such as the RelayBranch™ (Terumo Aortic) and Zenith Arch Branch™ (Cook Medical), the NEXUS™ device offers relevant technical advantages: standard femoral access, a smaller delivery diameter (20 Fr), reduced procedural time, and minimal aortic manipulation. However, it also carries important limitations: it requires favorable Zone 0 anatomy with a minimum aortic diameter of 30 mm and adequate proximal landing zone length, as well as an arch without excessive angulation or mural thrombus. Patient selection therefore remains a critical determinant of procedural success.

Finally, long-term surveillance remains indispensable. International consensus guidelines recommend CT imaging at 1, 6, and 12 months after the procedure, and annually thereafter, to detect late endoleak or material fatigue.

Current evidence supports that, in experienced hands, total endovascular aortic arch repair with dedicated systems is a safe, reproducible alternative with significant potential for broader application in the coming years.

Conclusions

The use of the NEXUS™ endograft in this case showed that complex aortic arch pathology can be safely and effectively treated in patients at high surgical risk. The absence of neurological and vascular complications reinforces the viability of this approach. Further studies are needed to assess the long-term impact of this treatment strategy and to establish its feasibility in a larger patient cohort.

1. Beatriz Acuña, Juan J. Legarra, Jorge Vidal, Jose M. Encisa, Miguel Á. Piñón, Tratamiento endovascular del arco aórtico con la prótesis NEXUS™: experiencia inicial de un centro, Cirugía Cardiovascular, Volume 29, Issue 2, 2022, Pages 72-78, ISSN 1134-0096, https://doi.org/10.1016/j.circv.2021.12.011

2. Callero‑Hernández, P. G., San Norberto, E. M., Cenizo, N., Flota, C. M., & Vaquero, C. (2025). Reparación endovascular del arco aórtico con prótesis NEXUS. REC: Interventional Cardiology. Advance online publication. https://doi.org/10.1016/j.recinterv.2025.01.056

3. Czerny M, Grabenwöger M, Berger T, et al. EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg. 2024.

4. Basha AM, Moore RD, Rommens KL, et al. A Systematic Review of Total Endovascular Aortic Arch Repair: A Promising Technology. Can J Cardiol. 2023;39(1):49-56.

5. Nana P, Spanos K, Dakis K, et al. Systematic Review on Customized and Non-customized Device Techniques for the Endovascular Repair of the Aortic Arch. J Endovasc Ther. 2022;29

6. Lindsay T, Ouzounian M, Tan K. Early Results of Arch Disease Treated with Nexus Arch Endograft. J Vasc Surg. 2017;66:E67.

7. D’Onofrio A, Lachat M, Mangialardi N, et al. Three-year follow-up of aortic arch endovascular stent grafting with the Nexus device: results from a prospective multicentre study. Eur J Cardiothorac Surg. 2022;63

8. Antonello M, et al. Results from the Italian Nexus aRCH endovascular repair registry for endovascular aortic arch repair. J Vasc Surg. 2025;82(4):1137-1145.

9. Czerny M, Schmidli J, Adler S, et al. Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: An expert consensus document of EACTS and ESVS. Eur J Cardiothorac Surg. 2019;55(1):133-162.

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Endovascular treatment of chronic type A aortic dissection, post-reparative surgery, with a novel endoprosthesis: first experience in Argentina

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