Assessment of Aortic Arch Morphology for Endovascular Interventions

doi:10.21203/rs.3.rs-2064249/v1

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Assessment of Aortic Arch Morphology for Endovascular Interventions

https://doi.org/10.21203/rs.3.rs-2064249/v1

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Introduction

: The aim of this study was to retrospectively classify the aorta according to the location of the supra-aortic vessels and analyze the aortic arch angle and angulation of supra-aortic branches on Multidetector Computed Tomography (MDCT) images, and contribute relevant data to the literature for use by interventional radiologists, neurologists, and cardiovascular and head-neck surgeons. Our secondary aim was to support the development of the “custom-made” thoracic stent grafts with the help of new data from the current study.

Materials and Methods

A total of 311 images (from 141 females and 170 males) that best suited our purpose were selected through archive screening. After creating three-dimensional reconstructions of the MDCT images, the aortic arch was divided into types according to the location of the brachiocephalic trunk. All images were viewed in the oblique coronal plane, where the angulation of the aortic arch and its branches can be best seen and measurements were obtained. Aortic arch types and angles were examined by age and sex.

Results

When the sex distribution of the aortic arch types was examined, Type 2 aortic arch was more common in males and Type 1 was more common in females. Regarding the age distribution of the aortic arch types, Types 1c and 2d were found only in the 18–44 age group and Types 3a and 3b were only detected in individuals over the age of 65. These findings suggest that aortic arch configuration changes with advancing age. Analysis of the relationship between age and vessel angulation showed only a weak positive correlation between age and aortic arch angle. Aortic arch angle showed a weak negative correlation with the angulation of supra-aortic vessels but a weak positive correlation was found among the angles of supra-aortic branches (p < 0.05; r < 0.4). A significant difference between sexes was observed in terms of the left subclavian artery angle and left common carotid artery angle, which were greater in males than in females (p < 0.05).

Conclusion

Variations in the angulation of the aortic arch and supra-aortic branches may trigger stroke by causing hemodynamic abnormalities. We believe that our findings may help the design of endograft used for endovascular arch repair.

Aortic arch type

aortic arch angle

angulation of supra-aortic branches

endovascular

The anatomy of the aortic arch and its branches varies from person to person [15]. Endovascular approaches to the aortic arch are challenging due to the unique anatomy and physiology of this region. Patients with aortic arch abnormalities often have features that are associated with an increased surgical risk including advanced age, systemic comorbidities or prior sternotomy and arch aneurysms, particularly after repair of acute aortic dissection [14]. Aortic arch disease is a challenging clinical problem, especially in high-risk patients in whom open repair may be associated with a morbidity rate of 30%-40% and a mortality rate of 2%-20% [24]. It is important to ensure adequate endovascular coverage of the lesion in the aortic arch without interrupting the collateral flow to the supra-aortic vessels [18]. Therefore, the morphological structure of the aortic arch and its branches should be explored and clearly understood in order to apply endografts that can accommodate to many anatomical structures [18, 23]. On the other hand, a thrombus originating from the heart may be affected by the morphological and hemodynamic features of the aortic arch, which in turn, affects the laterality and prognosis of cardioembolism [8, 11].

The aim of this study was to retrospectively classify the aorta according to the location of the supra-aortic vessels and analyze the aortic arch angle and angulation of supra-aortic branches on MDCT images, and contribute relevant data to the literature for use by interventional radiologists, neurologists, and cardiovascular and head-neck surgeons. Our secondary aim was to support the development of the “custom-made” thoracic stent grafts with the help of new data from the current study.

For this study, archived images of patients undergoing thoracic MDCT examination for various reasons at Gaziantep University Faculty of Medicine between 2017 and 2021 were reviewed retrospectively. Among these, 313 images that best suited our purpose were chosen for the study.

Exclusion criteria: Poor image quality due to motion artifacts or insufficient distribution of contrast material, absence of aortic arch and its branches in the field of view and patients with supra-aortic branches coming off from a single trunk which could unfavorably affect angle measurements were excluded.

Of 313 images, 142 images were from females and 171 from males. The mean age of the patients was 55.77±19.48 years. All measurements were obtained by the same investigator. The data were anonymized to avoid identification of the patients.

A 64-detector MDCT (Light Speed VCT XTe; General Electric, Milwaukee, USA) was used to acquire patient images. 120 ml of non-ionic contrast agent with an iodine concentration of 300 mgI/ml was injected into the right or left antecubital vein with the help of an automated injector (Covidien LF OptiVantage DH, Ohio, USA) as a bolus at a rate of 4 ml/sec, followed by 40 ml of saline at a rate of 4 ml/sec. The following parameters were used for all scans: collimation, 40 mm (64x0.625); pitch value, 1; tube rotation time, 0.35 sec; X-ray tube operating at 100-120 kV and 150-600 milliampere; detector thickness, 0.625 mm; reconstruction interval, 0.625 mm.

Three-dimensional (3D) reconstructions of two-dimensional (2D) MDCT images were made using the 3D Slicer, version 4.13.0 (https://www.slicer.org), an open source software package. Following transfer of the images to the 3D Slicer software, automatic thresholding was performed but since this process was insufficient, bone and other anatomical structures around the aorta were removed manually on the software. All images were viewed in the oblique coronal plane, where the angulation of the aortic arch and its branches can be best seen. The oblique coronal plane was determined using the guiding lines in the 3D reconstruction of the 3D slicer software.

First, transverse lines were drawn tangential to the outer and inner curvature of the aortic arch in order to classify aortic arch types [20]. The location of the brachiocephalic trunk was determined using these lines and the aortic arch configuration was divided into three types [7,10,16,17]. Then, these configurations were divided into subtypes based on the location of other supra-aortic vessels (Fig. 1):

Aortic arch configuration

Type 1: Brachiocephalic trunk (BCT) is above the upper line.

Type 1a (normal configuration): if all supra-aortic branches (left subclavian artery (LSA), left common carotid artery (LCCA) and BCT) are above the upper line,

Type 1b: if LSA is between the two lines and others are above the upper line,

Type 1c: if BCT is above the upper line and other are between the two lines.

Type 2: Brachiocephalic trunk is between the two lines.

Type 2a: if LSA is above the upper line and other branches are between the two lines,

Type 2b: if BCT is between the two lines and others are above the upper line,

Type 2c: if all supra-aortic branches are between the two lines,

Type 2d: if common carotid artery (CCA) is above the upper line and other branches are between the two lines.

Type 3: Brachiocephalic trunk is below the lower line.

Type 3a: if LSA is between the two lines and others are below the lower line,

Type 3b: if BCT is below the lower line and others are between the two lines.

The midpoints of both the ascending and descending aorta (at the point where the truncus pulmonalis emerges) were determined manually. The aortic arch angle was measured by drawing lines connecting these midpoints to the top of the arch. In the same way, the midpoints of the supra-aortic branches were marked manually, and their angles were measured where they originate from the aortic arch, parallel to the ground (Fig. 2). Since different methods were used for angle measurements, we could not identify a standard method used for this purpose [2,4,15,18,23,26]. Therefore, we also chose to measure the angles of aortic arch and its branches parallel to the ground in order to avoid measurement errors in the face of variations.

Statistical analysis

Descriptive statistics of the study data were summarized as mean and standard deviation for numerical variables, and frequency and percentage for categorical variables. Whether the angle measurements followed a normal distribution was examined using Shapiro-Wilk test. Except for aortic arch angle (AAA), all variables were normally distributed (p<0.05). For categorical variables, Independent samples t-test and Mann-Whitney U test were used for comparisons between two groups, and Analysis of Variance (ANOVA) and Kruskal-Wallis test to compare more than two groups. Differences among the groups identified by ANOVA and Kruskal-Wallis test were further analyzed using Tukey and Dunn tests. The results of statistical analyses were reported as mean ± standard deviation for the variables following a normal distribution and as median (Q1-Q3) for non-normally distributed variables. In addition, Chi-square test was used to examine the differences among the groups in terms of categorical variables. The associations between numerical variables were investigated using Pearson correlation and Spearman correlation analyses. All statistical analyses were performed using SPSS for Windows, version 22.0 (IBM Corp., Armonk, NY). The statistical significance level was set at p<0.05.

In this study, we first determined the types of aortic arch (AA) with reference to the brachiocephalic trunk. When we examined the distribution of individual aortic arch types by sex, Type 1 aortic arch was found in 99 (47.83%) males and 108 (52.17%) females, Type 2 in 68 (67.33%) males and 33 (32.67%) females and Type 3 in 4 (80%) males and 1 (20%) female (Table 1). Type 1 AA configuration was significantly more common in females and Type 2 was significantly more common in males (p < 0.05).

Table 1

Distribution of aortic arch types by sex
	Aortic arch type			p
	1	2	3
	N (%)	N (%)	N (%)
Male	99 (47.83)	68 (67.33)	4 (80)	0.003*
Female	108 (52.17)	33 (32.67)	1 (20)	0.003*

N: Number of individuals

The mean age was 52.27 ± 19.57 years for patients with Type 1 AA, 62.09 ± 17.28 years for patients with Type 2 AA and 74.4 ± 7.83 for patients with type AA. The mean age of the patients with Type 1 AA was significantly lower compared to other groups (p < 0.05) (Table 2). When we classified aortic arch types according to age groups, there were 4 (1.3%) patients with Type 1a AA, 3 (1.0%) patients with Type 1b AA, 2 (0.6%) patients with Type 2a AA and 1(0.3%) patient with Type 2b AA in the 0–17 age group. Other types of aortic arch were not observed in this age group. For the 18–44 age group, there were 57 (18.3%) patients with Type 1a AA, 6 (1.9%) patients each with Types 1b and 2a AA, 3 (1.0%) patients with Type 1c AA, and 1 (0.3%) patient each with Types 2b and 2d, with no other types found in this age group. In the 45–64 age group, there were 56 (18.0%) patients with Type 1a AA, 9 (2.9%) patients with Type 1b AA, 17 (5.5%) patients with Type 2a AA, 4 (1.3%) patients with Type 2b AA, and 12 (3.9%) patients with Type 2c AA. Other types were absent in this age group. Among patients aged 65 years or older, Type 1a AA was detected in 64 (20.6%) patients, Type 2a AA in 30 (9.6%) patients, Types 1b and 2b in 4(1.3%) patients each, Type 2c AA in 22 (7.1%) patients, Type 3a AA in 2 (0.6%) patients, and Type 3b AA in 3(1.0%) patients, with no patients with Types 1c and 2d (Fig. 3).

Table 2

Distribution of aortic arch types and mean age of the patients
Aortic arch type	N	\(\stackrel{-}{X}\)±SD	p
Type 1	207	52.27 ± 19.57^a	0.001*
Type 2	101	62.09 ± 17.28^b
Type 3	5	74.4 ± 7.83^b
Total	313	55.79 ± 19.39
*p < 0.05; a,b: Different letters indicate difference between the aortic arch types (Tukey’s test), N: Number of individuals, \(\stackrel{-}{X}\): Mean, SD: Standard Deviation

When we examined whether there was a difference between sexes in mean angles of the aortic arch and supra-aortic branches, a significant difference was observed for the left subclavian artery (LSA) and left common carotid artery (LCCA) angles (p < 0.01), with males exhibiting greater mean values than females (Table 3).

Table 3

Mean angle measurements of aortic arch and supra-aortic branches by sex
	SEX				p
	Male		Female
	Mean ± SD	Median (Q1-Q3)	Mean ± SD	Median (Q1-Q3)
AAA	81.91 ± 9.01	81.25 (76.1–87.9)	82.31 ± 8.65	82.7 (77-87.5)	0.554^Ψ
LCCAA	64.14 ± 16.88	65.7 (52.9–74.8)	54.03 ± 15.51	53.85 (43.5-65.65)	0.001* ^ƞ
BCTA	87.99 ± 17.77	87.8 (75.5-100.3)	84.02 ± 20.9	85.3 (67.3–99.4)	0.075 ^ƞ
LSAA	57.71 ± 15.63	58.8 (45.9–68.7)	49.06 ± 16.39	50.05 (38.9–59)	0.001* ^ƞ
p < 0.05; ^Ψ: Mann-Whitney U test, ^ƞ: t-test, AAA: aortic arch angle, LCCA: left common carotid artery angle, BCTA: brachiocephalic trunk angle, LSAA*: left subclavian artery angle, SD: Standard Deviation.

Looking at the relationship between age and angulation of the vessels, only aortic arch angulation showed a weak positive correlation with age (p = 0.001, r = 0.252). When we examined the relationships among vessel angles, we found a weak negative correlation between the aortic arch angle and all individual angles of supra-aortic branches (p = 0.000, r < 0.4). Analysis of correlations among the angles of supra-aortic branch vessels showed a moderate positive correlation between LSA and common carotid artery (CCA) (r = 0.543) and weak positive correlations between LSA angle and other branch angles as well as among the angles of other branches (r < 0.4) (p = 0.000) (Table 4).

Table 4

Correlation of age with vessel angulation.
		AAA	LCCAA	BCTA	LSAA
AGE	r	0,252	-,023	-,011	-,027
	p	0,001	,690	,841	,628
	N	312	311	312	313
AAA	r		-,299^**	-,211^**	-,351^**
	p		,000	,000	,000
	N		310	311	312
LCCAA	r			,372^**	,543^**
	p			,000	,000
	N			311	311
BCTA	r				,255^**
	p				,000
	N				312
p < 0,05; Pearson and Spearman correlation analyses, AAA: aortic arch angle, LCCA: left common carotid artery angle, BCTA: brachiocephalic trunk angle, LSAA*: left subclavian artery angle, r: correlation coefficient, N: Number of individuals

Lastly, we examined the relationship between the aortic arch types and the angles of aortic arch and supra-aortic branches, significantly greater aortic arch angle was found for Type 1 AA configuration compared to Types 2 and 3 (p < 0.05). LCCA angle and LSA angle was significantly smaller in Type 1 AA configuration in comparison to those of other groups (p < 0.05) (Table 5). Due to small number of patients with Type 3 AA configuration, it was not possible to determine whether there was a difference between Type 2 and Type 3 AA configurations.

Table 5

Distribution of angle measurements for the aortic arch and supra-aortic branches by aortic arch type
	Aortic arch type						p
	1		2		3
	Mean ± SD	Median (Q1-Q3)	Mean ± SD	Median (Q1-Q3)	Mean ± SD	Median (Q1-Q3)
AAA	83.95 ± 7.95	84.1 (79-88.8)^a	78.55 ± 9.55	79 (74.3 -84.95)^b	75.92 ± 5.02	76.6 (73.4–78)^b	0.001* ^Ψ
LCCAA	53.83 ± 15.36^a	53.8 (42.2–65.7)	70.15 ± 14.27^b	70.2 (62 -79.7)	82.32 ± 12.19^b	85.6 (79.6–90.6)	0.001* ^ƞ
BCTA	84.44 ± 20.11	85.9 (72.1–98.8)	89.39 ± 17.54	87.9 (78.2–102)	94 ± 11.1	92.5 (87.8–97.1)	0.072 ^ƞ
LSAA	48.13 ± 14.55^a	47.9 (38.9–58.3)	64.29 ± 14.55^b	63.2 (54.8–74.4)	75.54 ± 8.99^b	73,5 (70.5–79.8)	0.001* ^ƞ
p < 0.05, ^Ψ: Kruskal-Wallis test, ^ƞ: Analysis of Variance, a,b: Different letters indicate difference between the types (^Ψ Dunn’s test; ^ƞ Tukey’s test), SD: Standard Deviation, AAA: aortic arch angle, LCCA: left common carotid artery angle, BCTA: brachiocephalic trunk angle, LSAA*: left subclavian artery angle.

Thoracic endovascular aortic repair (TEVAR) is associated with relatively low rates of morbidity and mortality compared to open surgical repair. However, untoward complications may occur during a TEVAR procedure, including endoleak and stroke. It has been reported that successful results can be achieved with TEVAR depending on the aortic arch morphology and the ability of the endograft to seal off the pathological area [3]. Endovascular procedures for the aortic arch still lack standardization and reproducibility despite continuous technological advances [27]. The results underscore the need for a range of stent-graft models ideally with custom-made devices since a standard model is unlikely to meet the requirements of a population [5]. Characterization of the aortic arch morphology is essential for appropriate device selection and advances in stent-graft technology [3].

Variations of the aortic arch have been reported to have a major impact on mortality, myocardial infarction, stroke, type B aortic dissection and type B intramural hematoma, resulting in longer procedural times for carotid artery stenting and greater requirement for contrast agents [16, 17, 21]. In a study investigating the role of aortic geometry on stroke propensity, it was demonstrated that stroke propensity increases with increased aortic arch angulation in normal flow conditions, and a significant increase in stroke propensity occurs under atrial fibrillation flow condition if the aortic arch angle is < 90° [8]. In a separate study, patients with aortic dissection and aneurysm showed significantly longer ascending aorta compared to trauma patients, indicating changes in the aortic arch type [3].

In the literature, the aortic arch is broadly categorized into 3 types according to the relationship between the brachiocephalic trunk and the aortic arch, whereas in this study, we obtained a wider range of types by further dividing these 3 types into subtypes [7, 10, 16, 17, 21]. Considering the clinical importance of delineation of the origin and angulation of the supra-aortic branches and their differential roles in hemodynamic flow and clinical symptoms, it is our belief that a more comprehensive categorization of the aortic arch types may ultimately help improve treatment strategies.

There are many studies indicating the effect of sex and age on the aortic morphology of the thoracic region [9]. Some studies have shown that aortic arch diameter increases with age and is greater in males than in females [6, 13]. Similarly, we found greater LCCA and LSA diameters in males compared to females. Also, in line with Huang et al.’s (2019) findings, there was no difference between sexes in aortic arch angulation in our study. In studies examining the association of angulation of supra-aortic branches with age, while Zamir et al. did not find a correlation with age, Demertzis et al. reported a positive correlation between take-off angles of LCCA and LSA and age [3, 29]. In our study, we found a weak negative correlation between age and the mean angles of the aortic arch and its branches, and a weak positive correlation among the angles of the supra-aortic branches. In a study examining the aortic arch angle on CT images, it was reported that arch tortuosity is significantly increased in bicuspid aortic valve disease, leading to an increased risk of thoracic aortic aneurysm or dissection [4].

In a study on patients with cardioembolic stroke, Elsaid et al. (2020) reported that aortic arch type is significantly associated with age, and that the arch length increases with advancing age, which results in a deviation from the classic aortic arch type [11]. In parallel with Elsaid et al.’s findings, in our study, aortic arch variants of Types 3a and 3b were only found in older individuals (over the age of 65), who also displayed aortic arch Types 2a and 2c more commonly compared to other age groups. In another study investigating the relationship between stroke and aortic configuration, an increased incidence of stroke was reported in individuals with aortic arch types other than the classic arch type [20].

Huang et al. (2019) reported that patients with type A aortic dissection have greater angulation of aortic arch and its branches compared to healthy subjects, and suggested that this should be taken into account to increase treatment success when using stent grafts and endovascular treatment approaches [12, 13]. In contrast, Gode et al. (2019) reported that that the risk of developing type A aortic dissection increases in patients with acute aortic arch angulation [12, 13].

In a study by Suh et al. investigating the angulation of supra-aortic branches in patients with aortic aneurysm and aortic dissection, a significantly smaller LCCA angle was found compared to angulation of other branches [23]. In our study, the LSA showed the narrowest angle but in line with the aforementioned study, BCT angulation was large. We think that the difference in angle measurement method may have resulted in the discrepancy between Suh et al.’s results and ours. However, we consider that the large BCT angle observed in both studies is related to the fact that it is the first vessel branching off the aortic arch and arises more steeply compared to other branches. In another study, it was reported that supra-aortic branching angles were reduced in dissection patients, with further reduction observed in aneurysm patients [3]. In light of the data discussed above, the differences in these angles should be considered when designing or selecting endografts and ideally, choice of stent-graft should be individualized based on the patient and the disease.

In one study examining the impact of the anatomical structures of the aortic arch and its branches on the success of the dual-filter Sentinel™ Cerebral Protection System (Sentinel-CPS) application, it was found that changes in the angulation of the aortic arch and carotid artery had no effect on treatment success, whereas a brachiocephalic trunk angle of greater than 59° caused failure of the application [25]. In the current study, the majority of the BCT angles were greater than 50°, with a mean of 86.20°. Greater BCT angles observed in our study may be explained by the use of a different methodology for angle measurements.

There are studies reporting that in patients with acute ischemic stroke, endovascular mechanical thrombectomy prolonged the time to access the occluded site as well as fluoroscopy time (by 30 minutes) when the CCA angle was too small [19].

The choice of angiographic catheters to be inserted to the head and neck region depends on the angulation of the aortic arch and supra-aortic branches. It has been reported that the use of the Simmons catheter is more appropriate for patients with narrow left carotid artery angle [1]. Endovascular approaches to the aortic arch have been reported to be challenging in the case of poor angulation of the supra-aortic branches or when there are too many curves [22]. In such cases, the risk of embolism in intracranial vessels increases when cerebral angiography is performed through the aortic arch [22].

Another study examining the factors affecting diagnostic cerebral angiography using the transradial approach showed a positive correlation between time to cannulate left vertebral artery (VA) and left VA take-off angle and a negative correlation between the left common carotid artery (LCCA) take-off angle and time to cannulate left CCA [28]. This shows that the angulation of the aortic arch and its branches not only affects the diagnosis and treatment of the disease, but also has an impact on the procedure time and success of the technical approaches involving head and neck region.

Variations of the aortic arch and supra-aortic branches and differences in their angulation may trigger stroke by causing hemodynamic abnormalities. We believe that our findings may guide selection of the technique to be used for endovascular approaches involving the aortic arch. A number of limitations should be noted for this study. Since the study sample consisted of patients without aortic arch pathologies, a comparison with patients with arch pathologies such as dissection and aneurysm could not be made. It should be considered that since changes in the morphological and morphometric characteristics of the aortic arch occur in different aortic pathologies, such changes will affect the choice of stent-graft.

Ethics approval

This retrospective chart review study involving human participants was conducted in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Ethical approval dated 13.07.2021 and numbered 2021/37 was obtained from the Ethics Committee for Non-Invasive Clinical Research of Gaziantep Islam Science and Technology University.

Informed consent

A formal informed consent procedure was waived due to the retrospective nature of this study.

Competing Interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Availability of data and materials

The data that support the findings of this study are available from the corresponding author, [RT], upon reasonable request.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors

Author contributions:

C Omer Faruk: Protocol/project development, data collection, manuscript writing/review

T Rabia: Protocol/project development, data project development, manuscript writing/review

Y Sedat: Data collection and analysis, manuscript review.

Aboulhoda BE, Ahmed RK, Awad AS. Clinically-relevant morphometric parameters and anatomical variations of the aortic arch branching pattern. Surg Radiol Anat. 2019;41:731–44. https://doi.org/10.1007/s00276-019-02215-w.
Agnoletti G, Ou P, Celermajer DS, Boudjemline Y, Marini D, Bonnet D, Aggoun Y. Acute angulation of the aortic arch predisposes a patient to ascending aortic dilatation and aortic regurgitation late after the arterial switch operation for transposition of the great arteries. J Thorac Cardiovasc Surg. 2008;135:568–72. https://doi.org/10.1016/j.jtcvs.2007.10.020.
Alberta HB, Takayama T, Smits TC, Wendorff BB, Cambria RP, Farber MA, Jordan WD, Patel V, Azizzadeh A, Rovin JD, Matsumura JS. Aortic Arch Morphology and Aortic Length in Patients with Dissection, Traumatic, and Aneurysmal Disease. Eur J Vasc Endovasc Surg. 2015;50:754–60. https://doi.org/10.1016/j.ejvs.2015.08.005.
Alhafez BA, Truong VTT, Ocazionez D, Sohrabi S, Sandhu H, Estrera A, Safi HJ, Evangelista A, Hurtado LD, Guala A, Prakash SK. Aortic arch tortuosity, a novel biomarker for thoracic aortic disease, is increased in adults with bicuspid aortic valve. Int J Cardiol. 2019;284:84–9. https://doi.org/10.1016/j.ijcard.2018.10.052.
Allardyce H, Shepherd E, Bailey EL. Anatomical variation of the aorta in the West of Scotland - A population with high cardiovascular disease burden. Implications for stent design and deployment. J Anat. 2022. https://doi.org/10.1111/joa.13652.
Boufi M, Guivier-Curien C, Loundou AD, Deplano V, Boiron O, Chaumoitre K, Gariboldi V, Alimi YS. Morphological Analysis of Healthy Aortic Arch. Eur J Vasc Endovasc Surg. 2017;53:663–70. https://doi.org/10.1016/j.ejvs.2017.02.023.
Chiu P, Lee HP, Venkatesh SK, Ho P. Anatomical characteristics of the thoracic aortic arch in an Asian population. Asian Cardiovasc Thorac Ann. 2013;21:151–9. https://doi.org/10.1177/0218492312449637.
Choi HW, Luo T, Navia JA, Kassab GS. Role of Aortic Geometry on Stroke Propensity based on Simulations of Patient-Specific Models. Sci Rep. 2017;7:7065. https://doi.org/10.1038/s41598-017-06681-3.
d'ostrevy N, Ardellier FD, Cassagnes L, Ouchchane L, Azarnoush K, Camilleri L, Sakka L. The apex of the aortic arch backshifts with aging. Surg Radiol Anat. 2017;39:703–10. https://doi.org/10.1007/s00276-016-1792-9.
Demertzis S, Hurni S, Stalder M, Gahl B, Herrmann G, Van den Berg J. Aortic arch morphometry in living humans. J Anat. 2010;217:588–96. https://doi.org/10.1111/j.1469-7580.2010.01297.x.
Elsaid N, Bigliardi G, Dell'Acqua ML, Vandelli L, Ciolli L, Picchetto L, Borzì G, Ricceri R, Pentore R, Vallone S, Meletti S, Saied A. The Relation Between Aortic Arch Branching Types and the Laterality of Cardio-Embolic Stroke. J Stroke Cerebrovasc Dis. 2020;29:104917. https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104917.
Gode S, Akinci O, Ustunısık CT, Sen O, Kadirogulları E, Aksu T, Ersoy B, Gurbak I, Duman ZM, Erentug V. The role of the angle of the ascending aortic curvature on the development of type A aortic dissection: ascending aortic angulation and dissection. Interact Cardiovasc Thorac Surg. 2019;29:615–20. https://doi.org/10.1093/icvts/ivz144.
Huang F, Liu WX, Wu H, Lai QQ, Cai C. The Role of Dual-Source Computed Tomography Angiography in Evaluating the Aortic Arch Vessels in Acute Type A Aortic Dissection: A Retrospective Study of 42 Patients. Med Sci Monit. 2019;25:9933–8. https://doi.org/10.12659/msm.919678.
Hui DS, Fleischman F. Diagnostic and Treatment Dilemmas of the Aortic Arch. Cardiol Clin. 2017;35:347–55. https://doi.org/10.1016/j.ccl.2017.03.012.
Jalali Kondori B, Asadi MH, Rahimian E, Tahsini MR. Anatomical Variations in Aortic Arch Branching Pattern. Arch Iran Med. 2016;19:72–4.
Knox JA, Alexander MD, McCoy DB, Murph DC, Hinckley PJ, Ch'ang JC, Dowd CF, Halbach VV, Higashida RT, Amans MR, Hetts SW, Cooke DL. Impact of Aortic Arch Anatomy on Technical Performance and Clinical Outcomes in Patients with Acute Ischemic Stroke. AJNR Am J Neuroradiol. 2020;41:268–73. https://doi.org/10.3174/ajnr.A6422.
Marrocco-Trischitta MM, Rylski B, Schofer F, Secchi F, Piffaretti G, de Beaufort H, Belvroy V, Bismuth J, Czerny M, Trimarchi S. Prevalence of type III arch configuration in patients with type B aortic dissection. Eur J Cardiothorac Surg. 2019;56:1075–80. https://doi.org/10.1093/ejcts/ezz137.
Mazzaccaro D, Sciarrini M, Nano G. Analysis of origin of the supra-aortic trunks from the aortic arch. J Vasc Surg. 2018;67:399–408. https://doi.org/10.1016/j.jvs.2017.04.076.
Mokin M, Waqas M, Chin F, Rai H, Senko J, Sparks A, Ducharme RW, Springer M, Borlongan CV, Levy EI, Ionita C, Siddiqui AH. Semi-automated measurement of vascular tortuosity and its implications for mechanical thrombectomy performance. Neuroradiology. 2021;63:381–9. https://doi.org/10.1007/s00234-020-02525-6.
Müller MD, Ahlhelm FJ, von Hessling A, Doig D, Nederkoorn PJ, Macdonald S, Lyrer PA, van der Lugt A, Hendrikse J, Stippich C, van der Worp HB, Richards T, Brown MM, Engelter ST, Bonati LH. Vascular Anatomy Predicts the Risk of Cerebral Ischemia in Patients Randomized to Carotid Stenting Versus Endarterectomy. Stroke. 2017;48:1285–92. https://doi.org/10.1161/strokeaha.116.014612.
Shen S, Jiang X, Dong H, Peng M, Wang Z, Che W, Zou Y, Yang Y. Effect of aortic arch type on technical indicators in patients undergoing carotid artery stenting. J Int Med Res. 2019;47:682–8. https://doi.org/10.1177/0300060518807604.
Shin IY, Chung YG, Shin WH, Im SB, Hwang SC, Kim BT. A morphometric study on cadaveric aortic arch and its major branches in 25 korean adults: the perspective of endovascular surgery. J Korean Neurosurg Soc. 2008;44:78–83. https://doi.org/10.3340/jkns.2008.44.2.78.
Suh GY, Beygui RE, Fleischmann D, Cheng CP. Aortic arch vessel geometries and deformations in patients with thoracic aortic aneurysms and dissections. J Vasc Interv Radiol. 2014;25:1903–11. https://doi.org/10.1016/j.jvir.2014.06.012.
Voskresensky I, Scali ST, Feezor RJ, Fatima J, Giles KA, Tricarico R, Berceli SA, Beck AW. Outcomes of thoracic endovascular aortic repair using aortic arch chimney stents in high-risk patients. J Vasc Surg. 2017;66:9–20.e23. https://doi.org/10.1016/j.jvs.2016.11.063.
Voss S, Campanella C, Burri M, Trenkwalder T, Sideris K, Erlebach M, Ruge H, Krane M, Vitanova K, Lange R. Anatomical reasons for failure of dual-filter cerebral embolic protection application in TAVR: A CT-based analysis. J Card Surg. 2021;36:4537–45. https://doi.org/10.1111/jocs.16025.
Wang L, Hou K, Xu X, Chen B, Jiang J, Shi Z, Tang X, Guo D, Fu W. A simple patient-tailored aortic arch tangential angle measuring method to achieve better clinical results for thoracic endovascular repair of type B aortic dissection. J Thorac Dis. 2018;10:2100–7. https://doi.org/10.21037/jtd.2018.03.72.
Wilbring M, Rehm M, Ghazy T, Amler M, Matschke K, Kappert U. Aortic Arch Mapping by Computed Tomography for Actual Anatomic Studies in Times of Emerging Endovascular Therapies. Ann Vasc Surg. 2016;30:181–91. https://doi.org/10.1016/j.avsg.2015.07.018.
Yaser Arafath M, Bhatia V, Kumar A, Chauhan R, Prabhakar A, Gupta SK, Singh P. (2022) Adapting to transradial approach in cerebral angiography: Factors influencing successful cannulation. Neuroradiol J:19714009221111090. https://doi.org/10.1177/19714009221111090.
Zamir M, Sinclair P. Origin of the Brachiocephalic Trunk, Left Carotid, and Left Subclavian Arteries from the Arch of the Human Aorta. Invest Radiol. 1991;26:128–33. https://doi.org/10.1097/00004424-199102000-00007.

No competing interests reported.

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Assessment of Aortic Arch Morphology for Endovascular Interventions

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