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How should the proximal aortic landing zone for endovascular repair be configured and optimised?

A frozen elephant trunk (FET) procedure should be considered, providing a platform that can be extended distally with endovascular devices at a later stage.

I first perform supra-aortic debranching to create an adequate proximal landing zone and then implant a standard TEVAR, which can, if necessary, be angulated proximally (depending on the used device).

I use a branched aortic stent-graft, either an off-the-shelf or a custom-made device, to maintain perfusion of the supra-aortic branches while establishing a suitable proximal landing zone.

I intentionally cover the left subclavian artery with a standard TEVAR and perform left subclavian revascularisation only if required, either by surgical debranching or in-situ fenestration

How should we manage the kinked aorta and the varying aortic diameters during endovascular treatment?

Most contemporary endovascular devices will adequately accommodate this anatomy. If necessary, a tapered or staged stent-graft configuration can be selected.

I treat the entire aortic pathology in a single procedure in order to avoid additional interventions at the groins and access vessels and to minimise the need for further procedures associated with anesthesia risk.

The fewer stent-grafts, the better. In this case, precise matching to all changes in aortic diameter is not strictly required.

Outer-curve measurements will most reliably estimate the overall stent-graft length required. To adapt to the anatomical configuration and to prepare for a possible distal extension, I choose tapered devices.

What do you consider the key measures to reduce the risk of spinal cord ischemia?

Preservation of the left subclavian artery, strict peri- and post-operative blood pressure management, a staged approach to allow collateralisation, and a percutaneous strategy to maintain peripheral perfusion.

I consider the MISACE strategy, with pre-interventional occlusion of segmental spinal arteries, to be a highly reliable method of preventing spinal cord ischemia.

A short operative time is, for me, the decisive factor in reducing the risk of spinal cord ischemia.

I routinely place a pre-operative cerebrospinal fluid (CSF) drain, which I believe allows long-segment stenting with only moderate risk of spinal cord ischemia.

Because of the inherent baseline risk associated with CSF drain placement, I only insert a drain if spinal cord ischemia occurs post-operatively (rescue CSF drainage).