Endovascular stent grafting for ascending aorta repair in high-risk patients

Case Report: Coil embolization of ascending aortic pseudoaneurysm in patient with Behcet's disease

Background

Behcet's disease (BD) is a systematic vasculitis that affects vessels with various sizes, presenting as venous thrombosis and arterial pseudoaneurysms. The most severe manifestation in BD is ascending aortic pseudoaneurysm, which is associated with high risks of rupture and mortality.

Case presentation

We present a case of ascending aortic pseudoaneurysm in a 50-year-old patient with BD. After preoperative evaluation, coil embolization was successfully performed to treat the pseudoaneurysm, resulting in a satisfactory outcome at the 1-year follow-up.

Conclusion

Coil embolization serves as an effective treatment option for ascending aortic pseudoaneurysm in BD when open surgical repair and stent graft placement are unsuitable.

Endovascular repair of ascending aortic pathologies in patients unfit for open surgery: case series and literature review

The number of vascular centers performing endovascular repair of ascending aortic disease is constantly increasing. Accordingly to the guidelines, open surgical repair remains the gold standard for these pathologies. However, approximately one quarter of patients are deemed unfit for open surgery. In this study, we describe three cases of ascending thoracic endovascular aortic repair (TEVAR) performed at our center. All the patients were deemed unfit for open surgery by the aortic team. Two patients had an ascending aortic pseudoaneurysm, and the third had a focal type A aortic dissection. In two cases, we used two abdominal aortic cuffs deployed from zone 0B to zone 0C, with no need for supra-aortic trunk debranching. In one case, we performed a "reverse" extrathoracic debranching, and we deployed a thoracic endograft from zone 0B to zone 2. Complications included one minor stroke and one inguinal hematoma. In one patient with an infected pseudoaneurysm, we performed ascending TEVAR as a bridge strategy for open repair. This patient developed a type Ia endoleak; however, clinical stabilization and infection control were obtained, and he was able to undergo heart surgery successfully. He underwent a second reintervention to treat superior mesenteric embolic occlusion. At 2 years of follow-up, all three patients were alive. Our preliminary experience demonstrates the technical feasibility and clinical appropriateness of ascending TEVAR using standard, commercially available endografts. However, no consensus has been reached regarding some critical aspects, such as the development of a standardized technique or the efficacy of the currently available devices. The improvements in graft design and the adoption of the "aortic team" approach could help in the near future to standardize the procedure, establish appropriate indications, and ensure good clinical outcomes.

Long-term outcomes after recurrent acute thoracic aortic dissection: Insights from the International Registry of Aortic Dissection

OBJECTIVE

With an aging population and advancements in imaging, recurrence of thoracic aortic dissection is becoming more common.

METHODS

All patients enrolled in the International Registry of Aortic Dissection from 1996 to 2023 with type A and type B acute aortic dissection were identified. Among them, initial dissection and recurrent dissection were discerned. The study period was categorized into 3 eras: historic era, 1996 to 2005; middle era, 2006 to 2015; most recent era, 2016 to 2023. Propensity score matching was applied between initial dissection and recurrent dissection. Outcome of interests included long-term survival and cumulative incidence of major aortic events defined by the composite of reintervention, aortic rupture, and new dissection.

RESULTS

The proportion of recurrent dissection increased from 5.9% in the historic era to 8.0% in the most recent era in the entire dissection cohort. In patients with type A dissection, propensity score matching between initial dissection and recurrent dissection yielded 326 matched pairs. Kaplan-Meier curves showed similar long-term survival between the 2 groups. However, the cumulative incidence of major aortic events was significantly higher in the recurrent dissection group (40.3% ± 6.2% vs 17.8% ± 5.1% at 4 years in the initial dissection group, P = .02). For type B dissection, 316 matched pairs were observed after propensity score matching. Long-term survival and the incidence of major aortic events were equivalent between the 2 groups.

CONCLUSIONS

The case volume of recurrent dissection or the ability to detect recurrent dissection has increased over time. Acute type A recurrent dissection was associated with a higher risk of major aortic events than initial dissection. Further judicious follow-up may be crucial after type A recurrent dissection.

Deep learning-based radiomics of computed tomography angiography to predict adverse events after initial endovascular repair for acute uncomplicated Stanford type B aortic dissection

PURPOSE

This study aimed to construct a predictive model integrating deep learning-derived radiomic features from computed tomography angiography (CTA) and clinical biomarkers to forecast postoperative adverse events (AEs) in patients with acute uncomplicated Stanford type B aortic dissection (uTBAD) undergoing initial thoracic endovascular aortic repair (TEVAR).

METHODS

We retrospectively evaluated 369 patients treated with TEVAR for acute uTBAD from January 2015 to December 2022. A three-dimensional (3D) deep convolutional neural network (CNN) automated radiomic feature extraction from CTA images. Feature selection, using Analysis of Variance (ANOVA) and the Least Absolute Shrinkage and Selection Operator (LASSO) algorithms, refined a radiomic score (Rad-Score). This score, alongside clinical parameters, was modelled via Extreme Gradient Boosting (XGBoost) analysis. Model calibration was assessed by calibration curves.

RESULTS

The integration of the Rad-Score with clinical factors including albumin and C-reactive protein levels moderately enhanced predictive efficiency, exhibiting an area under the curve (AUC) of 1.000 (95%CI, 1.000-1.000) in the training cohort and 0.990 (95%CI, 0.966-1.000) in the internal validation cohort. In an independent validation cohort from another hospital, the combined model yielded an AUC of 0.985 (95%CI, 0.965-1.000), with an accuracy, precision, sensitivity, and specificity of 0.92, 0.92, 0.94, and 0.91, respectively.

CONCLUSIONS

The synergistic application of deep learning-based radiomics from CTA and clinical indicators holds promise for anticipating AEs post-initial thoracic endovascular aortic repair in patients with acute uTBAD. The clinical utility of the constructed combined model, offering prognostic foresight during follow-up, has been substantiated.

Case Report: Successful endovascular treatment of acute type A aortic dissection

Introduction

Open surgical repair remains the current gold standard for the treatment of acute type A aortic dissection. However, especially elderly patients with relevant comorbidities who are deemed unfit for open surgery may benefit from a minimally invasive endovascular approach.

Methods

We report a case of an 80-year-old male with retrograde acute type A aortic dissection and peripheral malperfusion after receiving thoracic endovascular aortic repair due to thoracic aortic aneurysm. Our individualized endovascular approach consisted of left carotid-subclavian bypass, proximal extension of thoracic endovascular aortic repair using a covered stent graft and a single covered stent graft for the ascending aorta in combination with an uncovered stent for the aortic arch.

Results

Postoperative computed tomographic angiography demonstrated excellent outcome with no signs of endoleak or patent false lumen. Follow-up after 3.5 years showed a stable result with no signs of stent failure or dissection progress. No aortic re-interventions were needed in the further course.

Discussion

An individualized endovascular approach may be justified for acute type A aortic dissection in elderly patients with high surgical risk if performed in specialized aortic centers. Additional short-length stent graft devices are needed to address the anatomical challenges of the ascending aorta. For enhanced remodeling of the dissected aorta, the use of an additional uncovered stent may be advisable.

Sex-Specific Morphometric Analysis of Ascending Aorta and Aortic Arch for Planning Thoracic Endovascular Aortic Repair: A Retrospective Cohort Study

OBJECTIVE

In many studies on aortic disease, women are underrepresented. The present study aims to assess sex-specific morphometric differences and gain more insight into endovascular treatment of the ascending aorta (AA) and arch.

METHODS

Electrocardiogram-gated cardiac computed tomography scans of 116 consecutive patients who were evaluated for transcatheter aortic valve replacement were retrospectively reviewed. Measurements of the AA and aortic arch were made in multiplanar views, perpendicular to the semi-automatic centerline. Multiple linear regression analysis was performed to identify predictors affecting AA and aortic arch diameter in men and women. Propensity score matching was used to investigate whether sex influences aortic morphology.

RESULTS

In both sexes, body surface area (BSA) was identified as a positive predictor and diabetes as a negative predictor for aortic diameters. In men, age was identified as a positive predictor and smoking as a negative predictor for aortic diameters. Propensity score matching identified 40 pairs. Systolic and diastolic mean diameters and AA length were significantly wider in men. On average, male aortas were 7.4% wider than female aortas, both in systole and diastole.

CONCLUSIONS

The present analysis demonstrates that, in women, increased BSA is associated with increased aortic arch diameters, while diabetes is associated with decreased AA and arch diameters. In men, increased BSA and age are associated with increased AA and arch diameters, while smoking and diabetes are associated with decreased AA and arch diameters. Men were confirmed to have 7.4% greater AA and arch diameters than women.

CLINICAL IMPACT

Men had 7.4% greater ascending aorta and arch diameters than women in a retrospective cohort, gated computed tomography-based study of 116 patients. Sex-specific differences in ascending aortic and arch size should be considered by aortic endovascular device manufacturers and physicians when developing ascending and arch endografts and planning aortic interventions.

Emergency and Compassionate Use of a Novel Ascending Endograft for Ascending and Arch Aortic Pathology

PURPOSE

Patients with complicated ascending aortic pathology, including patients with acute type A aortic dissection may be at extreme risk for open repair. Thoracic endovascular aortic repair (TEVAR), infrequently used for the ascending aorta, may be considered an alternative in this setting. We describe early results for emergency and compassionate (E&C) use of a novel endograft, specifically designed for use to treat pathology of the ascending aorta.

MATERIALS AND METHODS

This case series evaluated 19 patients (mean age, 68.84±13.12 years; 57.9% female) treated with ascending TEVAR for acute and chronic acute (4), subacute (1), or chronic (1) aortic dissection or pseudoaneurysm (13). Six of the 19 patients (31.5%) were treated under compassionate use and 13 patients (68.4%) were treated under the emergency use exemption. Ten patients (52.6%) received additional devices to extend treatment into the arch and descending aorta.

RESULTS

Device delivery was achieved in all patients (100%). Thirty-day mortality and stroke occurred in 3 patients (15.8%) and in 1 patient (5.3%), respectively. In 1 patient (5.3%), with an Unanticipated Adverse Device Event, the aorta ruptured when the endograft eroded into the adventitial portion of dissection site at the posterior aspect of the ascending wall. Devices were explanted in 2 patients (10.5%), 353 and 610 days after the index procedure, respectively. Six patients had endoleaks (31.6%), including type I (n=2, 10.5%), type II endoleaks (n=3, 15.8%), and indeterminate endoleak (n=1, 5.3%).

CONCLUSIONS

Delivery and deployment of a novel ascending thoracic stent graft with or without an additional branched arch extension is feasible in patients with complex anatomy and pathology, including acute aortic dissection and pseudoaneurysm. Additional experience with this novel device will further refine the patient population most suitable for endovascular ascending aortic repair for these pathologies.

CLINICAL IMPACT

This study describes a novel stent graft specifically designed for treatment of ascending aortic pathology, including acute type A dissection. The patients described in this series constituted a group outside the formal US FDA sponsored clinical trial, and were those accepted as part of an emergency and compassionate use basis.

Minimally Invasive Endovascular Repair for Nondissected Ascending Aortic Disease: A Systematic Review

Objective

The aim of this study is to evaluate the efficacy of endovascular treatment for nondissected diseases of the ascending aorta. Data Sources. PubMed, Embase, and SciELO. Review Methods. In this study, we conducted a search on the PubMed, Embase, and SciELO databases for all cases of ascending aortic endovascular repair included in the literature published between January 2007 and July 2023, excluding type A aortic dissection. We reviewed 56 case reports and 7 observational studies included in this study, assessing the techniques, equipment, procedural steps, and results. We summarized the age, complications, follow-up time, and access route.

Results

This study includes 63 articles reporting 105 patients (mean age: 64.96 ± 17.08 years) who received endovascular repair for nondissected ascending aortic disease. The types of disease include aneurysm (N = 16), pseudoaneurysm (N = 71), penetrating aortic ulcer (N = 10), intramural hematoma (N = 2), thrombosis (N = 2), iatrogenic coarctation (N = 1), and rupture of the aorta (N = 3). The success rate of surgery is 99.05% (104/105). Complications include endoleak (10.48%, 11/105), stroke (5.71%, 6/105), postoperative infection (1.91%, 2/105), acute renal failure (0.95%, 1/105), aortic rupture (0.95%, 1/105), thrombosis (0.95%, 1/105), and splenic infarction (0.95%, 1/105). Five patients required conversion to open surgery, two patients underwent endovascular reintervention, and four of these five patients underwent surgery due to endoleak. Early mortality was 2.86% (3/105).

Conclusion

While the viability and results of endovascular repair for the treatment of ascending aortic disease are acknowledged in some circumstances, further research is needed to determine the safety and effectiveness of endovascular treatment for ascending aortic disease.

Feasibility and safety of Stanford A aortic dissection complete endovascular repair system in a porcine model

BACKGROUND

Acute type A aortic dissection (ATAAD) is a catastrophic disease with high morbidity and mortality. Although open surgery is still the gold standard for the treatment of ATAAD, some patients, with advanced age and multiple comorbidities, can only receive medical management alone. Nowadays, thoracic aortic endovascular repair (TEVAR) provides a potential treatment option for the patient with ATAAD, but traditional stent grafts (SGs), which are not designed for the ATAAD, are inapplicable to the unique anatomy of the aortic arch. Therefore, we innovatively created the BRIDGE system (Chuangxin Medical, Shenzhen, China), a complete endovascular reconstruction system designed to treat ATAAD. This study aimed to evaluate the feasibility and safety of the novel Stanford A aortic dissection complete endovascular reconstruction system in a porcine model.

METHOD

The BRIDGE system consists of the type A stent system and the type C stent system. Between November 2020 and March 2021, three white swine were utilized in the study. The BRIDGE system was deployed via the transcatheter approach under angiographic guidance. The swine(n = 3) treated with our system were evaluated using angiography before sacrifice 1-month after implantation, which was followed by gross specimen evaluation and histological examination of harvested tissues.

RESULT

The acute procedure success rate was 100% (3/3). The immediate post-procedural angiography showed that both type A SGs and type C SGs were deployed in satisfactory locations, with patency of the supra-aortic trunk and no endoleak. The cumulative mortality of 30-day was 0% without any adverse events. No device migration or leakage was observed angiographically, before sacrifice. The gross observation confirmed a type A SG covered part of the entry of anonyma. Favorable endothelialization, no thrombogenesis, and slight inflammatory infiltration of the tissues around the device were confirmed by microscopic examinations in all pigs.

CONCLUSION

It was feasible and secure to use Stanford A aortic dissection complete endovascular reconstruction system to implement a transcatheter endovascular repair in a porcine model. With this novel system, treating acute type A aortic dissection may be more efficient and secure in human.

Endovascular repair of ascending aorta pseudoaneurysm post-extracorporeal membrane oxygenation cannulation during pulmonary transplant

We demonstrated an endovascular technique excluding an ascending aorta pseudoaneurysm using an aortic extension. A 32-year-old woman, 3 years after lung transplantation with extracorporeal membrane oxygenation presented with an ascending aortic pseudoaneurysm. Vascular surgery was consulted after open repair was deemed high risk. An aortic extension stent graft was placed in a hybrid operating room with the aid of intraoperative transesophageal echocardiography. Ascending aorta pseudoaneurysms are complex and life-threatening complications. Traditional repair involves high surgical and anesthetic risks whereas endovascular treatment is technically feasible.

Ascending Aortic Endograft and Thoracic Aortic Deformation After Ascending Thoracic Endovascular Aortic Repair

PURPOSE

We aim to quantify multiaxial cardiac pulsatility-induced deformation of the thoracic aorta after ascending thoracic endovascular aortic repair (TEVAR) as a part of the GORE ARISE Early Feasibility Study.

MATERIALS AND METHODS

Fifteen patients (7 females and 8 males, age 73±9 years) with ascending TEVAR underwent computed tomography angiography with retrospective cardiac gating. Geometric modeling of the thoracic aorta was performed; geometric features including axial length, effective diameter, and centerline, inner surface, and outer surface curvatures were quantified for systole and diastole; and pulsatile deformations were calculated for the ascending aorta, arch, and descending aorta.

RESULTS

From diastole to systole, the ascending endograft exhibited straightening of the centerline (0.224±0.039 to 0.217±0.039 cm^-1, p<0.05) and outer surface (0.181±0.028 to 0.177±0.029 cm^-1, p<0.05) curvatures. No significant changes were observed for inner surface curvature, diameter, or axial length in the ascending endograft. The aortic arch did not exhibit any significant deformation in axial length, diameter, or curvature. The descending aorta exhibited small but significant expansion of effective diameter from 2.59±0.46 to 2.63±0.44 cm (p<0.05).

CONCLUSION

Compared with the native ascending aorta (from prior literature), ascending TEVAR damps axial and bending pulsatile deformations of the ascending aorta similar to how descending TEVAR damps descending aortic deformations, while diametric deformations are damped to a greater extent. Downstream diametric and bending pulsatility of the native descending aorta was muted compared with that in patients without ascending TEVAR (from prior literature). Deformation data from this study can be used to evaluate the mechanical durability of ascending aortic devices and inform physicians about the downstream effects of ascending TEVAR to help predict remodeling and guide future interventional strategies.

CLINICAL IMPACT

This study quantified local deformations of both stented ascending and native descending aortas to reveal the biomechanical impact of ascending TEVAR on the entire thoracic aorta, and reported that the ascending TEVAR muted cardiac-induced deformation of the stented ascending aorta and native descending aorta. Understanding of in vivo deformations of the stented ascending aorta, aortic arch and descending aorta can inform physicians about the downstream effects of ascending TEVAR. Notable reduction of compliance may lead to cardiac remodeling and long-term systemic complications. This is the first report which included dedicated deformation data regarding ascending aortic endograft from clinical trial.

Lengthwise regional mechanics of the human aneurysmal ascending thoracic aorta

The prognosis of patients undergoing emergency endovascular repair of ascending thoracic aortic aneurysm (ATAA) depends on defect location, with root disease bearing worse outcomes than proximal or distal aortopathy. We speculate that a spatial gradient in aneurysmal tissue mechanics through the length of the ascending thoracic aorta may fuel noted survival discrepancies. To this end, we performed planar biaxial testing on 153 root, proximal, and distal segments of ATAA samples collected from 80 patients receiving elective open surgical repair. Following data averaging via surface fitting-based interpolation of strain-controlled protocols, we combined in-vitro and in-vivo measurements of loads and geometry to resolve inflation-extension kinematics and evaluate mechanical metrics of stress, stiffness, and energy at consistent deformation levels. Representative (averaged) experimental data and simulated in-vivo conditions revealed significantly larger biaxial stiffness at the root compared to either proximal or distal tissues, which persisted as the entire aorta stiffened during aging. Advancing age further reduced biaxial stretch and energy storage, a measure of aortic function, across all ATAA segments. Importantly, age emerged as a stronger predictor of tissue mechanics in ATAA disease than either bicuspid aortic valve or connective tissue disorders. Besides strengthening the general understanding of aneurysmal disease, our findings provide specifications to customize the design of stent-grafts for the treatment of ATAA disease. Optimization of deployment and interaction of novel endovascular devices with the local native environment is expected to carry significant potential for improving clinical outcomes. STATEMENT OF SIGNIFICANCE: Elucidating the lengthwise regional mechanics of ascending thoracic aortic aneurysms (ATAAs) is critical for the design of endovascular devices tailored to the ascending aorta. Stent-grafts provide a less invasive alternative to support the long-term survival of ATAA patients ineligible for open surgical repair. In this study, we developed a numerical framework that combines semi-inverse constitutive and forward modeling with in-vitro and in-vivo data to extract mechanical descriptors of ATAA tissue behavior at physiologically meaningful deformation. Moving distally from the aortic root to the first ascending aortic branch, we observed a progressive decline in biaxial stiffness. Furthermore, we showed that aging leads to reduced aortic function and is a stronger predictor of mechanics than either valve morphology or underlying syndromic disorder.

Acute aortic dissection: evidence, uncertainties, and future therapies

Remarkable progress has become especially apparent in aortic medicine in the last few decades, leading to essential changes in how thoracic aortic dissection is understood and treated. This state-of-the-art review article addresses the mechanisms of acute aortic dissection, explaining the role of its primary entry location, proximal, and distal dissection extension in their clinical presentation and impact on the decision-making process towards the best treatment approach. The latest evidence on novel treatment methods for acute aortic syndromes is presented, and the diverse dissection classification systems that remain uncertain are discussed, which reveals the need for shared terminology and more clarity. Finally, future aspects are discussed in treating acute aortic dissection, such as the endovascular treatment of aortic dissection Type A and biomarkers for acute aortic syndromes.

Endovascular Intervention for Aortic Dissection Is "Ascending"

Ascending aorta diseases represent an important cause of mortality worldwide. Notably, acute and chronic thoracic aorta pathologies have increased during the last years, but medical therapy does not seem to influence their natural history. Currently, although open surgery is the first choice of treatment, many patients are still rejected or have poor outcomes. In this scenario, endovascular treatment is raised as a valuable option. In this review we describe the limitations of conventional surgery and the state-of-art of endovascular ascending aorta repair.

Hybrid Thoracic Aortic Repair and Aortic Valve-In-Valve Replacement for Chronic Type A Dissection

We describe a case of hybrid total thoracic aortic repair and valve-in-valve transcatheter aortic valve replacement in a high-risk patient with complicated chronic type A dissection and severe prosthetic aortic stenosis. The patient underwent a three-stage-procedure including aortic arch debranching, thoracic endovascular aortic repair of the ascending aorta, aortic arch and descending thoracic aorta, and direct aortic valve-in-valve replacement using transcatheter heart valve. The details of the procedures are described with a discussion of the challenges and the decision-making process.

A systematic review and meta-analysis of thoracic endovascular aortic repair with the proximal landing zone 0

Background

Thoracic endovascular aortic repair, initially intended for thoracic aortic disease treatment, has extended its application to the proximal zone of the aorta. However, the safety and surgical outcomes of extending the proximal landing zone into the ascending aorta (zone 0) in selected cases remain unknown. Thus, we performed a systematic review and meta-analysis of zone 0 thoracic endovascular aortic repair (TEVAR) to obtain a deeper understanding of its safety, outcomes, and trends over time.

Methods

A literature search was performed using PubMed, EMBASE, and Web of Science databases in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines, from January, 1997 to January, 2022. Only studies involving zone 0 TEVAR were included. The retrieved data from the eligible studies included basic study characteristics, 30-day/in-hospital mortality rate, indications, comorbidities, stent grafts, techniques, and complications. Summary effect measures of the primary outcomes were obtained by logarithmically pooling the data with an inverse variance-weighted fixed-effects model.

Results

Fifty-three studies with 1,013 patients were eligible for analysis. The pooled 30-day/in-hospital mortality rate of zone 0 TEVAR was 7.49%. The rates of post-operative stroke, type Ia endoleak, retrograde type A aortic dissection, and spinal cord ischemia were 8.95, 9.01, 5.72, and 4.12%, respectively.

Conclusions

Although many novel stent grafts and techniques targeting zone 0 TEVAR are being investigated, a consensus on technique and device selection in zone 0 TEVAR is yet to be established in current practice. Furthermore, the post-operative stroke rate is relatively high, while other complication rates and perioperative death rate are comparable to those of TEVAR for other aortic zones.

Abdominal Stent-Graft Treatment of Ascending Aortic Pseudoaneurysm Following Transcatheter Aortic Valve Implantation

An ascending aortic pseudoaneurysm is a potentially lethal complication in aortic procedures. We present a hybrid approach using surgical innominate artery access and the endovascular insertion of an abdominal stent-graft extension to successfully treat a zone 0 ascending aortic pseudoaneurysm in a patient with a prior valve-in-valve transcatheter aortic valve implantation.

Timing of Intervention for Aortic Intramural Hematoma

Intramural hematoma (IMH) is one of the acute aortic syndromes along with acute aortic dissection and penetrating aortic ulcer. The three conditions can occur alone or in combination with overlapping presentation. Medical, open surgical, and endovascular treatment is tailored depending on clinical presentation, timing, and location within the aorta. Among patients who present with acute IMH affecting the ascending aorta (Type A), urgent open surgical repair is considered the primary line of treatment in patients who are suitable candidates and unstable. The management of IMH in the descending aorta and aortic arch (Type B) is similar to that applied to treat acute dissections in the same segment. Medical treatment with sequential imaging is recommended in patients with uncomplicated course, and endovascular repair is indicated in patients with rupture, persistent pain, end-organ ischemia, or rapid aortic enlargement. This review discusses the ideal timing for treatment of IMH.

Ascending aorta thoracic endovascular aortic repair for infected pseudoaneurysm

A 70-year-old woman with a bioprosthetic aortic valve replacement for aortic valve endocarditis complicated by recurrent endocarditis and requiring homograft aortic root replacement 10 years earlier had presented at 1 month after her admission for pseudomonal bacteremia with right-sided chest pain. An aortic pseudoaneurysm, identified on computed tomography, was treated with an ascending aorta thoracic endovascular aortic repair using two overlapping abdominal aortic stent grafts in the ascending aorta. Postoperative and follow-up imaging demonstrated exclusion of the pseudoaneurysm with stable positioning of the stent grafts. Ascending aorta thoracic endovascular aortic repair can be performed safely with good short-term results in patients presenting with infected pseudoaneurysms of the ascending aorta.

ARISE: First-In-Human Evaluation of a Novel Stent Graft to Treat Ascending Aortic Dissection

BACKGROUND

Operative mortality for type A aortic dissection is still 10-20% at centers of excellence. Additionally, 10-20% are not considered as viable candidates for open surgical repair and not offered life-saving emergency surgery. ARISE is a multicenter investigation evaluating the novel GORE® Ascending Stent Graft (ASG; Flagstaff, AZ).

OBJECTIVE

The purpose of this study is to assess early feasibility of using these investigational devices to treat ascending aortic dissection.

METHODS

This a prospective, multicenter, non-randomized, single-arm study that enrolls patients at high surgical risk with appropriate anatomical requirements based on computed tomography imaging at 7 of 9 US sites. Devices are delivered transfemorally under fluoroscopic guidance. Primary endpoint is all-cause mortality at 30 days. Secondary endpoints include major adverse cardiovascular and cerebrovascular events (MACCE) at 30 days, 6 months, and 12 months.

RESULTS

Nineteen patients were enrolled with a mean age of 75.7 years (range 47-91) and 11 (57.9%) were female. Ten (52.6%) had DeBakey type I disease, and the rest were type II. Sixteen (84.2%) of the patients were acute. Patients were treated with safe access, (7/19 (36.8%) percutaneous, 10/19 (52.6%) transfemoral, 2/19 (10.5%) iliac conduit), delivery, and deployment completed in all cases. Median procedure time was 154 mins (range 52-392) and median contrast used was 111 mL (range 75-200). MACCE at 30 days occurred in 5 patients including mortality 3/19 (15.8%), disabling stroke in 1/19 (5.3%), and myocardial infarction in 1/19 (5.3%).

CONCLUSION

Results from the ARISE early feasibility study of a specific ascending stent graft device to treat ascending aortic dissection are promising.

Endovascular Repair for Ascending Aortic Graft Side Branch Pseudoaneurysm: A Report of Two Cases

Introduction

A pseudoaneurysm arising from the side branch of the prosthesis, following ascending aortic replacement, is extremely rare. Re-intervention usually involves open surgery, replacement of the ascending aorta, or ligation of the side branch. Redo surgery with an additional sternotomy carries the risk of cardiac and vascular injuries, and endovascular treatment can reduce such adverse events.

Report

This study describes the successful thoracic endovascular aortic repair (TEVAR) of two cases of pseudoaneurysms arising from the side branch after ascending aortic replacement. Case 1 involved a 79 year old man who underwent ascending aortic replacement and omentopexy for a ruptured tuberculous aortic aneurysm 13 years ago. The pseudoaneurysm was mushroom shaped with a 30 mm protrusion. Case 2 involved an 83 year old man who underwent ascending aortic replacement for Stanford type A acute aortic dissection 11 years ago. The pseudoaneurysm was rod shaped with a 27 mm protrusion. In both cases, the pseudoaneurysm arising from the side branch was not noted on computed tomography (CT) until one year earlier and was first identified at a routine follow up examination. The pseudoaneurysms required surgical repair because of the risk of rupture; however, TEVAR was selected considering the risks of redo surgery and the patients' ages. It was performed via a femoral artery approach without adverse events using a commercially available thoracic aortic device. Post-operative CT scan showed complete exclusion of the pseudoaneurysm.

Discussion

Although TEVAR is usually not indicated for ascending aortic pathologies, if there is an anatomical indication and a compatible stent graft, TEVAR for the ascending aorta should be the first choice in patients who are inoperable, at high risk and undergoing redo surgery.

Endovascular repair of the ascending aorta: the last frontier

Different pathologies of the ascending aorta (AA), including aneurysms, acute and chronic dissections, and pseudoaneurysms, have been treated with open surgical repair with very good results, especially at aortic centers of excellence. There is, however, a subset of patients for whom open surgery is considered to pose high or prohibitive risk. These patients can benefit from a less invasive approach with catheters and wires, percutaneous techniques and stent grafts. However, the existing technology was developed to treat descending thoracic aortic pathologies; it is not approved for use in the AA by the US Food and Drug Administration (FDA). The devices used for the descending thoracic aorta (DTA) have certain size and design limitations that make their application to the AA cumbersome at times. As a result, custom-made endografts have been used to treat pathologies in the AA, although their use is feasible only in elective procedures. In addition, the AA has specific anatomic and physiologic characteristics that raise concerns about the long-term durability of the current technology. In this review, we outline the limitations, challenges and current status of endovascular technology to treat pathologies of the AA.

Time-resolved, Cardiac-gated Computed Tomography after Endovascular Ascending Aortic and Arch Repair

PURPOSE

Better time-resolved imaging of stent grafts in ascending aorta and arch accounting for cardiac motion is necessary to understand device-related complications and endoleaks. We describe a novel dynamic time-resolved computed tomography-angiography (d-CTA) and its combination with electrocardiography-gating (d-gated-CTA) to image stent grafts in ascending aorta and to better characterize endoleaks.

DESCRIPTION

d-CTA involves multiple scans acquired at different timepoints along contrast enhancement curve. d-gated-CTA involves concomitant electrocardiography-gating in a pre-defined cardiac phase minimizing motion induced artifacts.

EVALUATION

We illustrate the utility of d-CTA and d-gated-CTA in two clinical scenarios. d-CTA demonstrated type 1A endoleak in a patient with aortic arch aneurysm treated by total arch debranching and thoracic stent graft. d-gated-CTA demonstrated type 1A endoleak in a patient with ascending aortic pseudo-aneurysm treated by aortic cuff placement.

CONCLUSIONS

Dynamic, cardiac-gated CTA enables time-resolved angiographic imaging of ascending aorta and arch without any cardiac motion related artifacts. Such advanced imaging techniques help with better characterization of endoleaks after stent-graft deployment in the ascending aorta and arch.

Alternative management of proximal aortic dissection: concept and application

Open surgery remains the mainstay of treatment for acute type A aortic dissection and should be offered to most patients. However, there are elderly patients in which surgical treatment may be deemed extremely high risk or futile. Endovascular treatment approaches have been applied to a small number of these patients and data are limited to case reports and small series. The application of endovascular therapies to ascending aorta is currently limited by anatomical and technical challenges posed by the dynamic motion of the ascending aorta and the proximity of vital structures to intended landing zones (aortic valve, coronary arteries, and supra-aortic branches) and lack of specially designed endografts to address these issues. While thoracic endovascular aortic repair (TEVAR) has replaced open aortic repair for a suitable lesion in distal aortic dissection, some selected patients with type A aortic dissection at high surgical may be candidates. Hence, there is potential because, in proximal (Stanford type A) dissections, 10–30% of patients are not accepted for surgery, and 30–50% are technically amenable for TEVAR. Recent experience has shown that carefully selected patients with favorable anatomical characteristics may be subject to endovascular stent-graft treatment as a last resort with mixed results. Technical improvement is necessary to offer. satisfactory endovascular options in non-surgical candidates.

Aortic Dissection: Branched, Fenestrated, and Parallel Aortic Stent Grafts in the Ascending Aorta and Arch

Open surgical repair of dissections and post-dissection degenerative aneurysms involving the ascending thoracic aorta and aortic arch, whether in the acute or post-repair state, is associated with high rates of morbidity and mortality. Recent advancements in minimally invasive endovascular techniques have expanded the role of thoracic endovascular aortic repair (TEVAR) for dissections and dissection-related arch pathologies. Image-guided endovascular techniques, such as in situ fenestrated grafts, chimney and/or periscope grafts, along with newly developed commercially available branched aortic devices, have allowed for an increasing number of high-risk operative candidates to undergo definitive repair of aortic arch pathology who otherwise would have been destined for non-operative management. This paper reviews the data, pre-procedural planning, and technical considerations for complex TEVAR techniques for ascending and aortic arch dissections and dissection-related aneurysms.

Towards Endovascular Treatment of Type A Aortic Dissection with Smaller Landing Zones and More Patient Eligibility

OBJECTIVE

Type A or ascending aortic dissection is an acute life-threatening condition with high morbidity and mortality. Open surgery remains standard-of-care. Development of minimally invasive endografts for Type A aortic dissection (TAAD) will require detailed understanding of dissection and aortic root anatomy to determine patient eligibility and optimal device specifications.

METHODS

Computed tomography images of TAAD cases at our institution from 2012-2019 were identified and three-dimensional reconstructions were performed using OsiriX 10.0 (Bernex, Switzerland). Analysis of key anatomic structures including centerline length measurements, ascending aorta/aortic root dimensions, as well as location and extent of dissection were determined in relation to coronary ostia.

RESULTS

A total of 53 patients were identified (mean±SD age 60.4±17.1 years; 36 male, 17 female), 46 of whom underwent surgery for TAAD. Four patients died within 30 days of surgery. In 47 patients (88.7%), the entry tear was distal to the highest coronary ostium. These cases were retrospectively considered for endovascular intervention with a non-branched, single endograft stent. Proximal landing zone (LZ) was defined as distance from the highest coronary ostium to entry tear: 35/53 (66.0%) had a proximal LZ length ≥2.0cm, 38/53 (71.7%) had proximal LZ length ≥1.5cm, and 42/53 (79.2%) had proximal LZ length ≥1.0cm. Proximal and distal LZ diameters of the sinotubular junction (STJ) and distal ascending aorta regions were (median [1^st quartile-3^rd quartile]) 3.29cm [2.73-4.10cm] and 3.49cm [3.09-3.87cm], respectively, with length from STJ to innominate takeoff 8.08cm [6.96-9.40cm]. Ascending aorta radius of curvature was 6.48cm [5.27-8.00cm]. 47.2% (25/53) of patients could be treated with a straight tube graft with ≤20% diameter mismatch between the proximal and distal LZ.

CONCLUSIONS

Almost 80% of patients with TAAD had a proximal LZ ≥1.0cm, and of these, 47.2% had anatomy amenable to endovascular therapy with a non-tapered straight tube graft commercially available devices. To increase patient eligibility for TAAD endovascular intervention, enhanced precision deployment with adequate seal in shorter LZs will be required. Our results serve as a guide for endovascular device specifications designed to treat this devastating condition.

Back-Table Modified Stent-Graft for Endovascular Repair of Ascending Aorta

OBJECTIVES

To investigate the effectiveness of modified stent-grafts (SGs) for the management of ascending aortic pathologies.

MATERIALS AND METHODS

From January 2015 to December 2019, 31 individuals were treated by ascending aortic endovascular repair with a back-table modified SG for acute (n=4) or chronic (n=1) type A aortic dissections, penetrating aortic ulcers (n=18), pseudoaneurysms (n=2), anastomotic fistula (n=1), and endoleaks after thoracic endovascular aortic repair (TEVAR) (n=5). The commercially available thoracic aortic SGs were modified with a fenestration or truncation technique on the back-table according to aortography during the operation.

RESULTS

The 30-day mortality and aorta-related mortality rates were 12.9% and 6.5%, respectively. There were 2 strokes, 3 respiratory insufficiencies, and 6 endoleaks during hospitalization. During a mean follow-up of 28.8±16.6 months, the overall survival rates at 1 year and 3 years were both 80.6%. Free from adverse event rates at 1 year and 3 years were 88.9% and 84.7%, respectively. There were 2 deaths during follow-up: One patient died of cachexia 1 month after discharge, and the other patient died of acute myocardial infarction 3 months after discharge. One patient with a pseudoaneurysm underwent open ascending aorta replacement 3 months after discharge for a type Ia endoleak. Another patient suffered from cerebellar infarction 17 months after discharge.

CONCLUSION

The modified SG for endovascular repair of the ascending aorta is a practicable alternative and presents acceptable outcomes in high-risk patients.

Successful Conservative Treatment of a Complicated Aortic Thrombus in a Woman with Factor V Leiden Mutation

Thrombus in the aortic trunk is a rare complication. We report the case of a 63-year-old patient with a factor V Leiden mutation in whom an aortic arch thrombus was discovered accidentally. Conservative treatment was initiated with therapeutic anticoagulation with low-molecular-weight heparin leading to complete thrombus lysis after 3 months but associated shortly after anticoagulation initiation with a large splenic and limited renal infarctions.

Post-operative Recurrent Ascending Aortic Pseudoaneurysm with Aorto-cutaneous Fistula- Endovascular management with an In-situ Stent-Graft Fenestration for the Innominate Artery

Ascending aortic pseudoaneurysm is a known complication of previous cardiac surgery that needs surgical or endovascular intervention. The presence of arch branches complicates the later approach necessitating additional procedures, either hybrid surgical or endovascular modification of the grafts. We describe a patient who developed an ascending aortic pseudoaneurysm after mitral valve replacement, which recurred after surgical patch closure with the formation of a cutaneous fistula. This high-risk patient was managed by an endovascular approach with in-situ fenestration for the innominate artery by a simple technique.

Percutaneous endovascular management of ascending aortic pseudoaneurysm after heart transplantation in a pediatric patient

Ascending aortic pseudoaneurysm is a rare complication after HT. Surgery is the most conventional management, but in some patients, it is risky. We report the case of a ten-year-old child who underwent HT and developed an ascending aortic pseudoaneurysm in the aortic anastomosis. He was successfully treated with two covered stents through endovascular management. Endovascular therapy is an alternative management in high-risk patients. To our knowledge, this is the first report about endovascular therapy of an AAP after HT in a pediatric patient.

Anesthetic Considerations in Endovascular Repair of the Ascending Aorta

Since the first endovascular aortic repair in 1990, endovascular devices and the indications for their use have significantly grown. Considerable progress has been made in endovascular devices and techniques, such that endovascular repair is now considered first-line treatment for patients with descending aortic disease. However, for patients with ascending aortic disease, open surgical repair with cardiopulmonary bypass and hypothermic cardiac arrest was the only option until recently. Although the outcomes for open surgical repair of the ascending aorta have improved over the years, approximately 30% of patients with an emergent surgical indication, such as type A aortic dissection, are considered to be too high risk for open repair. For these patients, endovascular repair of the ascending aorta offers a life-saving procedure. The ascending aorta is regarded as the final frontier for endovascular therapy. Endovascular repair of it has posed a formidable challenge thus far, due to its unique anatomy, hemodynamic forces, and lack of an appropriate stent-graft designed specifically for the ascending aorta. Although currently there are no comprehensive data from randomized clinical trials, there are several case series and case reports that have shown favorable outcomes. Improvements in available devices soon will drive an exponential increase in the number of patients undergoing endovascular ascending aortic repair. In this review, the authors discuss multiple aspects of endovascular ascending aortic repair including the unique surgical and anesthetic considerations, the devices used, and the available outcomes data, and future directions are also explored.

Endovascular Bail Out for a Failed Transcatheter Aortic Valve Implantation in High Surgical Risk Patient

The endovascular treatment for acute type A dissection (ATAD) represents an alternative and emerging option in selected high surgical risk patients. We report a successful total endovascular ATAD repair occurred intraoperatively during transcatheter aortic valve implantation (TAVI) placement in 82 years old female, not fit for surgery in emergency setting. The presentation, the diagnostic evaluation, and the technique are discussed. This case would support the feasibility and efficacy of the stent graft technology to treat ATADs after evaluation of clinical, anatomical, and radiological parameters.

Systematic review and meta-analysis of endovascular interventions for Stanford type A aortic dissection

OBJECTIVE

The standard surgical approach to Stanford type A aortic dissection is open repair. However, up to one in four patients will be declined surgery because of prohibitive risk. Patients who are treated nonoperatively have an unacceptably high mortality. Endovascular repair of the ascending aorta is emerging as an alternative treatment for a select group of patients. The reported rates of technical success, mortality, stroke, and reintervention have varied. The objective of the study was to systematically report outcomes for acute type A dissections repaired using an endovascular approach.

METHODS

The systematic review and meta-analysis was conducted in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. We performed online literature database searches through April 2020. The demographic and procedural characteristics of the individual studies were tabulated. Data on technical success, short-term mortality, stroke, and reintervention were extracted and underwent meta-analysis using a random effects model.

RESULTS

Fourteen studies with 80 cases of aortic dissection (55 acute and 25 subacute) were included in the final analysis. A wide variation was found in technique and device design across the studies. The outcomes rates were estimated at 17% (95% confidence interval [CI], 10%-26%) for mortality, 15% (95% CI, 8%-23%) for technical failure, 11% (95% CI, 6%-19%) for stroke and 18% (95% CI, 9%-31%) for reintervention. The mean Downs and Black quality assessment score was 13.9 ± 3.2.

CONCLUSION

The technique for endovascular repair of type A aortic dissection is feasible and reproducible. The results of our meta-analysis demonstrate an acceptable safety profile for inoperable patients who otherwise would have an extremely poor prognosis. Data from clinical trials are required before the technique can be introduced into routine clinical practice.

Hybrid stepwise external wrapping for type a acute aortic dissection with cerebral Malperfusion

Background

Acute aortic dissection (AAD) is a life-threatening condition which can lead to coronary, brachiocephalic or branch vessel malperfusion, as well as aortic valve insufficiency, or aortic rupture. Mortality of surgical treatment in high-risk or elderly patients with Type A AAD (TAAAD) still remains high, and treatment for such patients remains controversial. We report a successful treatment of TAAAD with a communicating false lumen in a 60-year-old man with acute hemi-cerebral malperfusion.

Case presentation

The ascending aorta was wrapped with stepwise external wrapping (SEW) procedure, and subsequent thoracic endovascular aortic repair (TEVAR) was successfully performed. The patient was discharged in good physical condition without any complications.

Conclusions

Hybrid therapy with SEW and TEVAR with TAAAD associated with major cerebral malperfusion should be considered, especially in patients for whom open surgery is extremely risky.

Endovascular ascending aortic repair in type A dissection: A systematic review

PURPOSE

Up to 10% of acute type A aortic dissection (TAAD) patients are deemed unfit for open surgical repair, exposing these patients to high mortality rates. In recent years, thoracic endovascular aortic repair has proven to be a promising alternative treatment modality in specific cases. This study presents a comprehensive overview of the current state of catheter-based interventions in the setting of primary TAAD.

METHODS

A literature search was conducted, using MEDLINE and PubMed databases according to PRISMA guidelines, updated until January 2020. Articles were selected if they reported on the endovascular repair of DeBakey Type I and II aortic dissections. The exclusion criteria were retrograde type A dissection, hybrid procedures, and combined outcome reporting of mixed aortic pathologies (e.g., pseudoaneurysm and intramural hematoma).

RESULTS

A total of 31 articles, out of which 19 were case reports and 12 case series, describing a total of 92 patients, were included. The median follow-up was 6 months for case reports and the average follow-up was 14 months for case series. Overall technical success was 95.6% and 30-day mortality of 9%. Stroke and early endoleak rates were 6% and 18%, respectively. Reintervention was required in 14 patients (15%).

CONCLUSION

This review not only demonstrates that endovascular repair in the setting of isolated TAAD is feasible with acceptable outcomes at short-term follow-up, but also underlines a lack of mid-late outcomes and reporting consistency. Studies with longer follow-up and careful consideration of patient selection are required before endovascular interventions can be widely introduced.

Acute Aortic Syndrome of Ascending Thoracic Aorta: Transcarotid Percutaneous Exclusion of a Ruptured Pseudoaneurysm

Treatment of ascending aorta disease is surgical; however, some series have evaluated the effectiveness of endovascular treatment. We report the case of a patient with a ruptured pseudoaneurysm who underwent endovascular repair via the left common carotid artery. The clinical and neurological evolution was satisfactory during the in-hospital follow-up. (Level of Difficulty: Intermediate.).

Tailored approaches for transcatheter closure of postsurgical pseudoaneurysms from the ascending aorta and brachiocephalic artery

Ascending aortic pseudoaneurysms following open-heart surgery are treated by redo surgery or endovascular therapy when surgical risks are high. Extreme variations in their morphology, proximity to coronary and arch branches and vascular access may vary the timing, strategy, device choice, and technique in each patient. Three patients with varying etiology, presentations, and morphology of the pseudoaneurysms underwent successful endovascular exclusion by individually tailored strategies. The approach includes optimal treatment of the underlying infections before the endovascular intervention despite the emergency to treat the condition; choosing appropriate device depending on the proximity to aortic branches, choosing appropriate access depending on the angulation of the entry of pseudoaneurysm to the aortic lumen, and use of adequate imaging for achieving procedural success. <Learning objective: A tailored approach for transcatheter closure of postsurgical ascending aortic pseudoaneurysms should include: 1 Optimal infection control before the intervention. 2 Choosing nitinol occluders in high-flow aneurysms; vascular plugs and coils for residual leaks; and embolic protection for high clot burden. 3 Choice of femoral, brachial, or transapical access is decided based on angulation of the aneurysm with ascending aorta. 4 Meticulous planning of the interventions based on advanced three-dimensional imaging.>.

Application of an extracorporeal prefenestrated stent graft in endovascular repair of ascending aorta and aortic arch lesions

OBJECTIVES

Aortic dissection involving the ascending aorta and aortic arch is a serious condition. Treatment using traditional surgical methods has certain disadvantages. This study investigated the effectiveness of thoracic endovascular repair of aortic dissection using an external prefenestrated stent.

METHODS

We present a series of aortic dissection cases involving the ascending aorta and aortic arch treated with an external prefenestrated stent.

RESULTS

Postoperative follow-up of the patients showed that all stents were released at the proper position and that branch vessels were not occluded, and there were no instances of type I endoleak. One patient died suddenly one week after surgery; another experienced retrograde type A aortic dissection in the second week; and type I endoleak occurred in one patient in the first week, although this resolved within six months. No serious complications such as cerebrovascular events, acute spinal cord ischemia, and paraplegia occurred during the perioperative period. All patients had false lumen thrombosis in the ascending aorta and aortic arch.

CONCLUSION

Prefenestrated stent grafting is a feasible treatment option for repairing an entry tear in the ascending aorta.

Catheter-based treatment of the dissected ascending aorta: a systematic review

OBJECTIVES

METHODS

A PubMed search was supplemented by searching through bibliographies and key articles. Demographics, risk score, stent graft detail, access route, mortality, cause of death, complications, reinterventions and follow-up data were extracted and analysed.

RESULTS

Thirty-one articles (7 retrospective reports; 24 case reports/series) were included in the study. In total, 104 patients (mean age 71 ± 14 years) received endovascular treatment for acute (63) or chronic (41) type A dissection. A history of a major cardiac or aortic operation was present in 29 patients. The mean EuroSCORE II was 30 ± 20 in 4 reports. A total of 114 stent grafts were implanted: ‘off-the-shelf’, 65/114; custom made, 12/114; and modified, 7/114. Hospital complications included intraprocedural conversion to open surgery (2/104), stroke (2/104), coronary stenting (2/104), early endoleak (9/104) and repeat aortic endovascular treatment for endoleak (5/104). Hospital mortality was 10% (intraoperative death 2/104). Mean duration of follow-up time was 21 ± 21 months (range 1–81 months); follow-up data were available for 86 patients: 10 patients died of non-aortic-related causes; reintervention for aortic disease (endovascular repair or open surgery) was performed in 8 patients.

CONCLUSIONS

Catheter-based ascending aorta repair for type A aortic dissection with the entry tear in the ascending aorta can be considered in carefully selected high-risk patients. Further analysis and specifically designed devices are required.

Post-traumatic Aortopulmonary Fistula after Bentall Procedure

Pseudoaneurysm complicated by aortopulmonary fistula (APF) after a Bentall procedure is extremely rare but potentially fatal, so timely diagnosis and treatment are critical. We present a subacute case of a post-traumatic APF which has had initial aspecific symptoms and later an acute worsening heart failure with chest pain not responding to medical treatment and requiring emergency surgery.

Zone 0 Thoracic Endovascular Repair After Aortic Wrapping for Acute Aortic Syndrome

We report a successful treatment of type A acute aortic syndrome (AAS)-associated aortic arch aneurysm in a 71-year-old man with major comorbidities. The ascending aorta was wrapped with artificial graft, and supra-aortic debranching was constructed. Then, Zone 0 thoracic endovascular aneurysm repair (TEVAR) with plug occlusion of the left subclavian artery was successfully performed. The patient was discharged in good physical condition without any complications. To our knowledge, this is the first reported case in the literature of successful Zone 0 TEVAR after ascending aorta wrapping and supra-aortic debranching with type A AAS associated with aortic arch aneurysm.

Thoracic endovascular aortic repair for an ascending aortic pseudoaneurysm

An 80-year-old woman underwent aortic valve replacement and ascending aortic replacement. Two years later, computed tomography revealed a pseudoaneurysm of the ascending aorta replaced with a prosthesis. The pseudoaneurysm arose from the stump of a side branch of the prosthesis. Endovascular treatment for the pseudoaneurysm was carried out using the aortic extension cuff of an infrarenal endovascular system. The postoperative course was uneventful.

Endovascular Repair of Ascending Aortic Pseudoaneurysm Using Transfemoral Frame-Coiling Under Total Cerebral Protection

Ascending aortic pseudoaneurysms are associated with prior cardiac surgery and have a high chance of rupture. Open surgery is challenging given its likely reoperative nature. Various endovascular therapies have been described but are sometimes complicated by stroke. We present a patient with a prior coronary artery bypass grafting who was referred for an incidental 3-cm saccular ascending aortic pseudoaneurysm who was successfully treated with frame coiling under total cerebral embolic protection using the SENTINEL device. We propose that endovascular obliteration of ascending aortic pseudoaneurysms is a viable option in patients unfit for open repair and advocate for total cerebral embolic protection as an important adjunct.

Early and midterm outcomes of in situ laser fenestration during thoracic endovascular aortic repair for acute and subacute aortic arch diseases and analysis of its complications

OBJECTIVE

An analysis was conducted of early and midterm outcomes of a large series of patients treated with in situ laser fenestration (ISLF) during thoracic endovascular aortic repair (TEVAR) of acute and subacute complex aortic arch diseases, such as Stanford type A aortic dissection (TAAD), type B aortic dissection (TBAD) requiring proximal sealing at zone 2 or more proximal, thoracic aortic aneurysm or pseudoaneurysm, and penetrating aortic ulcer. We present the perioperative and follow-up outcomes and discuss the rate of complications.

METHODS

This is a retrospective review of prospectively collected data from January 2017 to March 2019 of patients treated with TEVAR and ISLF of aortic arch branches at a large tertiary academic institution in an urban city in China. Preoperative, intraoperative, and follow-up clinical and radiographic data are analyzed and discussed.

RESULTS

A total of 148 patients presented with symptomatic and acute or subacute TAAD, TBAD, thoracic aortic aneurysm, or penetrating aortic ulcer for a total of 183 arch vessels. There were 105 men and 43 women, 21 to 79 years of age (mean, 54.9 ± 12.9 years). Time from symptom onset to time of surgery was an average of 7 ± 3 days. Survivor follow-up duration ranged from 5 to 24 months (mean, 15 ± 5 months). Single-vessel fenestration was carried out in 124 cases, two-vessel fenestration in 13 cases, and three-vessel fenestration in 11 cases. There were four cases with technical failure to laser fenestration, with a technical success rate of 97.3%. Postoperatively, there were seven cases of endoleak (4.7%; one type IB distal from the left subclavian artery branch stent graft, three type IIIC at the fenestration site, and three type II), three retrograde dissections (2.0%), and five strokes (3.4%); death occurred in three patients with 30-day mortality of 2.9%, and two deaths occurred during follow-up for 3.4% mortality at an average 15 months of follow-up. There was no branch stent graft occlusion or spinal ischemia postoperatively or during follow-up. The distribution of arch diseases varied significantly according to the number of vessels that were laser fenestrated; TAAD was more likely to receive multivessel laser fenestrations, and TBAD was more likely to receive single-vessel fenestration (P < .001). The rate of complications was distributed differently between the three ISLF groups, with more complications occurring in multivessel fenestrations. However, a statistical weakening was observed when frequency of complications between the three groups was stratified by type of arch disease. The complication rate varied significantly between the different arch diseases, higher in TAAD than in TBAD (P = .008).

CONCLUSIONS

ISLF during TEVAR for treatment of acute and subacute complex aortic arch diseases in the proximal aortic arch is safe and effective on the basis of these early to midterm follow-up data of a large cohort. However, care should be taken in intervening on TAAD using TEVAR with adjunctive multivessel laser fenestration. Continued investigation of TEVAR and adjunctive ISLF is needed to elucidate the long-term outcomes of this minimally invasive treatment for complex aortic arch disease in an urgent setting.