The heart as access to the aorta†

Abstract

Thoracic endovascular aortic repair (TEVAR) is an accepted treatment option for patients with thoracic aortic pathologies regarded as unfit for open surgery. Nevertheless, a subgroup of these patients is ineligible for classic TEVAR due to the lack of access vessels. We describe the transapical TEVAR technique enabling surgeons to perform TEVAR even in these patients.

Percutaneous access planning, techniques and considerations for endovascular aortic repair (EVAR)

“…This percutaneous approach can be used for thoracic aortic aneurysm repair in patients with severe peripheral arterial disease, highly unusual anatomy, or those with contraindications to arterial access due to calcification or narrowed effective lumen diameter of the iliac or femoral arteries. Because of the novelty of this technique, further investigation regarding the largerscale cost-effectiveness and safety is warranted; however, an early study has indicated a successful transcaval access and closure in 99 out of 100 attempts during TAVR procedures (28,33). The one complication in this study occurred when the guidewire failed to cross and the operator had to perform transfemoral artery TAVR, which was further complicated by iliac artery rupture.…”

“…Patients receiving transapical access are ineligible for a transfemoral approach often due to lack of access vessels, absence of femoral pulse, a severely atherosclerotic or kinked thoracic descending aorta, inherently narrow arterial diameter, type A aortic dissection, or ascending aortic aneurysm (22,(27)(28)(29). Compared to transfemoral access, the access via the left ventricular apex increases control for the proceduralist due to a straighter and shorter approach (23).…”

Endovascular treatment of the ascending aorta using a combined transapical and transfemoral approach

“…4 Also, the transapical approach for thoracic endovascular aortic repair of the descending aorta has been described. 5,6 However, suitability of the ascending aorta for endovascular repair is still limited by its anatomic and functional properties (three-dimensional curvature, coronary ostia and supra-aortic branches, effects of aortic compliance on pulse wave propagation).…”