Endovascular Treatment of the Ascending Aorta: is this the Last Frontier in Aortic Surgery?

Abstract

Regardless the successful treatment of the descending aorta with endovascular prosthesis, for the ascending aorta segment, because of several anatomic and physiologic issues, this technique has been considered an alternative only for high-risk or inoperable patients. Despite restricted indications, hundreds of treatments have been performed worldwide, demonstrating its safety and reproducibility if it is done in high-quality centers. Therefore, understanding patients’ selection criteria and technique limitations are critical to its application.

The ascending aorta and arch in the sights of transcatheter therapy: A time for reappraisal

“…These findings strengthen the preponderant role of the endovascular heart surgeon in the management of these procedures, where a combination of wire skill training and surgical proficiency encompassing all technical options available makes it distinctive and resourceful, which provides complete resolution to each multicomponent of this disease in one setting, besides the promptness to repair the inherent complications that will accompany these interventions 16 …”

“…repair the inherent complications that will accompany these interventions. 16 Conventional surgery and its technical variants will remain the treatment of choice for a large proportion of patients with type A AAD; however, ongoing progress points that interventional transcatheter procedures will continue to evolve, and a share of cardiovascular diseases may become amenable to this treatment approach.…”

“…In this way, the role of the cardiovascular surgery societies worldwide, partnering with medical device companies and establishing ongoing educational and training programs, with certification for heart surgeons who complete training, should support the prospect of acquiring these ground-breaking and complementary new skills. 16,17 Substantial more refinement and technological advance will be necessary before endovascular repair of type A AAD comes to wider use, making the ideal timespan for cardiovascular surgeons to be involved, and prepared to take on the challenges of leading this new enterprise.…”

“…The further trend toward referring patients with aorta diseases to centers of excellence, a policy aimed at achieving better outcomes and cost reduction, will add elements favoring the role of the surgeon in this multidisciplinary program. A pending issue is to determine which patient could most benefit from the emerging assorted array of therapeutic options, from surgical delay or permanent deferral of surgery to interventional transcatheter procedures with transfer to specialized centers 16,17 . Given the complexity of designing a randomized controlled trial in a disease with a multivariate presentation like type A AAD, a scoring system derived from a large dedicated database would be effective to predict the 30‐day mortality rate for patients undergoing surgery for type A AAD and provide recommendation for procedure selection 18 …”

“…Transcatheter procedures and open surgery will coexist side by side and be regarded as complementary rather than competing. In this way, the role of the cardiovascular surgery societies worldwide, partnering with medical device companies and establishing ongoing educational and training programs, with certification for heart surgeons who complete training, should support the prospect of acquiring these ground‐breaking and complementary new skills 16,17 …”