Endovascular approaches to the ascending aorta are right around the corner

Abstract

Endovascular technology has revolutionized the surgical management for patients with descending thoracic aortic pathology. Over the last decade, there has been growing interest in applying these technologies to treat various pathologies of the aortic arch and ascending aorta, primarily acute type A aortic dissection and ascending aortic pseudoaneurysm (AAP) (Figure 1). Several technical challenges remain, however. These include the complex anatomy of the aortic root; the close spatial relationships among the aortic root, ascending aorta, and aortic arch; and device dimensions currently designed for the descending thoracic aorta. Despite increasing experience with endovascular approaches to ascending aortic pathology, most published series to date are confined to patients deemed high risk for open surgical repair. [1][2][3] In this article, Li and colleagues 4 report their use of intraoperative transesophageal echocardiography and a 3D printing model to customize a nitinol mesh occlusion device for treatment of a large AAP. Interestingly, the etiology of this AAP was never elucidated. This creative technique is novel in its application of a 3D model derived from computed tomography images. The AAP was approached directly through a sternotomy incision, although this same intervention could conceivably could be done through a transapical left anterior thoracotomy approach, which has been described previously. 5 The AAP was relatively large, with a 2-cm neck. The authors fashioned the occlusion device off the 3D model to ensure proper sizing and achieve an effective seal and durable fixation.Presumably, the need to customize design of the occlusion device limits application to the nonemergency setting. Immediate and short-term follow-up imaging demonstrated effective obliteration of the pseudoaneurysm. The authors elected to not use anticoagulation owing to the hemodynamic forces in the ascending aorta, although data to guide this decision are lacking. This case description highlights several important points regarding innovation and the application of new technology and imaging modalities to treat various pathologies of the ascending aorta. First, innovation in surgery begins with FIGURE 1. Cook Zenith TX2 graft (Cook Medical, Bloomington, Ind) deployed via the transapical approach for acute type A dissection.

Anatomical Engineering and 3D Printing for Surgery and Medical Devices: International Review and Future Exponential Innovations

“…Arterial deformations caused by endovascular equipment depend on multiple factors, such as the morphology of the arteries, the state and degree of arterial calcification, and the type of device used [ 129 ]. At present, their prediction is mainly based on the surgeon's experience [ 130 ].…”