The evolution of endovascular aortic arch repair marks one of the most complex and technically demanding advancements in cardiovascular care. As outcomes improve and devices evolve, more centers are aiming to establish dedicated programs for total endovascular aortic arch repair (TEAAR). However, successful implementation requires more than just technical capability—it requires a highly coordinated system of care, proper infrastructure, experienced personnel, and institutional readiness.

At Aortic Academy, we’ve compiled this foundational guide to support hospitals, surgical centers, and academic institutions that wish to launch or formalize their own arch repair program.

1. Multidisciplinary Aortic Team

A successful arch program begins with a dedicated, collaborative team of subspecialists who manage complex aortic pathology from diagnosis through follow-up. At minimum, this team should include:

• • Vascular surgeons with experience in branched and fenestrated aortic procedures

• • Cardiac surgeons trained in arch surgery and comfortable with hybrid approaches

• • Interventional radiologists and cardiologists experienced in aortic imaging and endovascular navigation

• • Anesthesiologists trained in high-risk cardiovascular procedures with cerebral monitoring capability

• • Neurologists or neurointerventionalists for stroke risk management and pre-procedural evaluation

• • Intensive care specialists, perfusionists, and trained cath lab/hybrid OR nursing teams

• • A program coordinator or clinical manager to handle logistics, data, and multidisciplinary scheduling

This team must operate under structured clinical pathways, joint case reviews, and collaborative decision-making frameworks.

2. Physician Credentialing & Experience

Arch repair requires operators with significant experience in both thoracic endovascular aortic repair (TEVAR) and branched/fenestrated techniques. Institutional credentialing should require:

• • Documented case volume of complex aortic repairs (e.g. 25–50 TEVARs/year per operator)

• • Completion of device-specific training and proctored cases for branched arch devices

• • Familiarity with Zone 0–2 planning, cerebral protection strategies, and bailout conversion

• • Ongoing participation in case reviews, morbidity/mortality rounds, and registry contribution

Training and simulation programs—either in-house or through platforms like Aortic Academy—should support skill development.

3. Hybrid Operating Room Standards

A hybrid OR or advanced angiosuite is essential for safe, image-guided arch interventions. Minimum infrastructure should include:

• • Fixed high-resolution imaging (preferably monoplane or biplane fluoroscopy with 3D overlay capability)

• • Table-compatible with radiolucent carbon fiber surfaces, tilt/rotation capability

• • Integration of image fusion, rotational angiography, and real-time measurements

• • Space to accommodate a full open and endovascular team including anesthesiology and perfusion

• • Backup open surgical equipment readily available (sternotomy instruments, CPB circuit, suction, etc.)

Centers without a true hybrid OR must evaluate whether mobile C-arms and portable setups meet imaging and sterility standards—most guidelines recommend fixed imaging for arch work.

4. Devices & Ancillary Inventory

Endovascular arch repair requires highly specialized and comprehensive device support, including:

• • Branched or fenestrated aortic endografts (custom-made or off-the-shelf systems)

• • Bridging stents (self-expanding or balloon-expandable depending on target vessels)

• • Access kits for axillary, carotid, femoral, or transcaval approaches

• • Guidewires, sheaths, snares, pre-closure systems, perfusion circuits

• • Spinal cord protection kits, temporary pacing systems, and arterial pressure monitoring

• • Rapid access to cerebral embolic protection devices and stroke rescue equipment

Stocking and training staff on the use of contingency devices is equally critical (e.g. bare-metal stents, thoracic cuffs, chimney/snorkel strategies, and occlusion balloons).

5. Imaging & Preoperative Planning Requirements

Detailed anatomical assessment is a prerequisite for safe arch planning. Centers must have:

• • Access to high-resolution CTA with ECG-gating, 3D reconstruction, and thin-slice arch segmentation

• • Ability to perform centerline reconstructions and clock-face orientation of supra-aortic branches

• • Imaging software that allows planning for fenestration alignment, distance mapping, and angulation measurements

• • Preoperative assessment of Circle of Willis integrity and dominant vertebral artery via CTA or MR

• • Coordination with neurovascular and radiology teams for high-risk cerebrovascular anatomy

6. Anesthesia & Neuroprotection Standards

Aortic arch repair poses significant risk of cerebral ischemia and hemodynamic instability. Anesthesia protocols must include:

• • Cerebral monitoring tools such as bilateral near-infrared spectroscopy (NIRS)

• • Arterial line placement in both radial arteries (for detecting pressure gradients across arch vessels)

• • Transesophageal echocardiography (TEE) for wire and graft navigation

• • Rapid access to cardiopulmonary bypass (CPB) if emergent conversion is required

• • Ability to manage blood pressure augmentation or controlled hypotension as needed

Anesthesia teams must be specifically trained in aortic endovascular workflows, cerebral perfusion management, and crisis response.

7. Postoperative Care & Long-Term Follow-Up

Arch patients require meticulous post-op monitoring and structured imaging follow-up:

• • ICU team familiar with spinal cord perfusion, renal management, and stroke surveillance

• • Routine CTA at 1, 6, and 12 months, then annually

• • A dedicated outpatient aortic surveillance clinic

• • Documentation and integration into national or institutional aortic registries for quality control

8. Governance, Accreditation & Continuous Improvement

Launching a TEAAR program should include:

• • Formal institutional approval through cardiac/vascular service lines

• • Development of standard operating protocols (SOPs) for case selection, emergency response, and discharge

• • Participation in peer-reviewed outcomes tracking, including 30-day mortality, stroke rate, endoleak rate, and reintervention

• • Collaboration with training platforms and societies (such as Aortic Academy) for continued professional development

Conclusion

Establishing a Total Endovascular Aortic Arch Repair program is a significant but achievable milestone for any high-level cardiovascular center. With the right team, imaging capability, hybrid infrastructure, and governance, institutions can elevate the standard of care for patients with complex aortic arch disease.

At Aortic Academy, we are proud to support centers worldwide in developing the technical, procedural, and strategic readiness needed to enter this field. Stay tuned for future workshops, simulation modules, and case-based proctoring tools to help your team move from vision to reality.