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Complex arch pathologies such as mid-arch aneurysms, mega-aortic syndrome and residual arch and distal descending aortic dissection traditionally require two step solutions to achieve a complete repair. This typically involves an open repair of the arch with either a traditional elephant trunk or frozen elephant trunk technique followed by open descending repair or stent grafting. More recently, hybrid arch repair has become available. Hybrid repairs require surgical reconstruction to bring the supra-aortic vessels more proximally off the ascending aorta and placement of a stent graft in the ascending aorta distal to their take-off. As for any endovascular stent graft procedure, the proximal and distal landing zones are crucial. Chronic residual arch and distal aortic dissection from an incomplete previous DeBakey I acute dissection repair is a uniquely difficult problem due to the re-do status of the patient and the complexity of the flap in the distal arch. However, they typically have surgical graft proximal landing zones which facilitate proximal seal.  As device technology has improved, emerging therapies for total aortic arch replacement have recently developed using primarily endovascular approaches for patients who required landing into Zone 0. These include devices that have either a single branch and require a transposition or bypass to the left carotid and the left subclavian arteries or two branch devices that require bilateral carotid cut down, carotid-carotid bypass in the neck and left carotid-subclavian bypass.

Double transposition and single branched TEVAR for total arch replacement in chronic dissection