Endovascular Repair of Ascending Aortic Disease in High-Risk Patients Yields Favorable Outcome

Abstract

Background. Up to 30% of patients presenting with ascending aortic disease are deemed inoperable. Ascending aortic endovascular repair provides an alternative option for these patients.Methods. From 2018 to 2019, 13 patients who were considered to have prohibitive risk for open ascending aortic repair underwent endovascular repair. Aortic disease included type A dissection (n [ 8), pseudoaneurysm (n [ 3), penetrating ulcer (n [ 3), and chronic aortic aneurysm (n [ 1). Ascending aortic stent placement with thoracic endovascular aortic repair was performed in 9 patients, endovascular cuff extension was inserted in 3, and in 1 patient endovascular coil embolization was undertaken. Preoperative and follow-up electrocardiogram-gated computed tomographic analysis was performed to compare the remodeling effect of the stent on the aorta. The median follow-up time was 13 months.Results. The stent graft was successfully implanted in all patients (100%). Operative mortality and stroke rate were 15% (2 of 13) and 8% (1 of 13), respectively. One patient required transcatheter aortic valve replacement for severe aortic insufficiency 5 months after ascending thoracic endovascular aortic repair. The location of the aortic pathologic process was in zone 0A in 2 patients, zone 0B in 7 patients, and zone 0C in 3 patients. No endoleak was observed after the ascending endovascular repair in 9 patients (70%). Follow-up computed tomographic scan analysis revealed a tendency of favorable aortic remodeling in the mid-ascending and descending aorta.Conclusions. Ascending aortic stent placement for ascending aortic disease is feasible and is associated with favorable aortic remodeling. Despite persistent perfusion to the false lumen in a subset of patients, there is minimal aortic dilation at short-term follow-up with excellent survival.

Clinical Practice Variation and Outcomes for Stanford Type A Aortic Dissection Repair Surgery in Maryland: Report from a Statewide Quality Initiative

“…For example, ascending aortic endovascular stent grafts have been used in select high-risk patients with Stanford Type A aortic dissection and five such cases were done at the highest volume hospital during the 4-year study period. 13 14 15 All five patients survived to hospital discharge and there were no strokes observed. For these cases, percutaneous common femoral arterial access is obtained and a 10-cm endovascular stent graft is brought retrograde via the descending thoracic aorta into the proximal ascending aorta near the intimal tear.…”

“…This type of approach has been shown to have comparable short-term mortality when compared with open repair and a low rate of endoleak. 15 …”

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

“…53 Rare complications included stent graft induced new entry-tears (SINE; n = 2), accidental covering of branch vessels (n = 1), iatrogenic dissection (n = 1), and retained delivery systems (n = 1), all of which required open surgical repair. 35,36,45 Overall, 30-day mortality was 9% (Table 5), with breakdowns of 11%, 0%, and 4% for acute, subacute, and chronic type A dissection, respectively. The 30-day event-free survival (i.e., freedom from death, reintervention, or major complication) was 71%.…”

“…Open reinterventions were performed SINE (n = 3), 35,39 Type I endoleak (n = 1), 36 severe AI (n = 1), 22 PAU (n = 1), 38 iatrogenic femoral artery dissection (n = 1), 45 pseudoaneurysm (n = 2), 32,36 and pericardial effusion (n = 1). 45 Endovascular reinterventions were performed for Type I endoleak (n = 3) 35,36 and severe AI (n = 1). 45 2,54 It is important to note that, similar to type B aortic dissection, acuity of disease in TAAD impacts both patient presentation and outcome.…”

Thoracic Aortic Emergencies: Presenting Pathologies and Treatment Strategies

“…Endovascular repair of the ascending aorta and arch has been described in case reports, but there are ongoing trials investigating new devices specific for these anatomic zones. [34][35][36] The management of patients with acute type B aortic dissection (ATBAD) is based on complicated or uncomplicated patient presentations. Patients presenting with severe hypertension, persistent pain, malperfusion, or rupture are considered complicated.…”