Thoracic endovascular aortic repair (TEVAR) in proximal (type A) aortic dissection: Ready for a broader application?

Abstract

TEVAR is feasible and reveals promising early results in selected patients with type A aortic dissection who are poor candidates for surgical repair. The current iteration of stent-graft technology, however, needs to be adapted to features specific to the ascending aorta.

False lumen intervention to promote remodelling and thrombosis—The FLIRT concept in aortic dissection

“…FLIRT has proven safe, and feasible in 5 attempted cases of chronic type A dissection and is certainly less traumatic than other techniques including stenting of ascending aorta . Closure of entry tears, restoration of single‐lumen blood flow and enhanced FL thrombosis may reap long‐term benefits , without the risks of stent‐grafting the ascending aorta (Figure ). Hence, the FL channel is an alternative pathway to allow a catheter to reach the tear to deploy coils and Amplatzer TM vascular occluder devices in the FL.…”

“…FLIRT has proven safe, and feasible in 5 attempted cases of chronic type A dissection and is certainly less traumatic than other techniques including stenting of ascending aorta [29]. Closure of entry tears, restoration of single-lumen blood flow and enhanced FL thrombosis may reap long-term benefits [33], without the risks of stent-grafting the ascending aorta ( Figure 4). Finally, best timing of FLIRT as complimentary intervention is not clear yet, but better understanding of CT imaging may help to identify patients likely to benefit from FLIRT [34,35].…”

Endovascular treatment of acute Type A aortic dissection—the Endo Bentall approach

“…However, the use of TEVAR in the ascending aorta particularly in the setting of acute aortic dissection remains experimental (7). In fact, since the first successful endovascular ascending aortic repair in 2000, the largest case series consists of 45 patients that were treated with ascending aortic TEVAR and most reports consist only of few patients in high volume centers (4,(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19). Also, reports are either due to a favorable anatomy or due to very localized disease processes, which are the exception and not the rule.…”

Novel Endovascular Management of Proximal Type A (DeBakey II) Aortic Dissection With a Patent Foramen Ovale Occluder

“…suitable anatomy (6). Challenges are the proximity of the tear to the aortic root and coronaries, and the shape of the ascending aorta and the arch.…”

“…In other words, the intimate spatial relationship between vital structures of the aortic root and the available device dimensions, not designed for the ascending aorta, portend serious limitations. Attempts to use endovascular stent-grafts for interventional management of the false lumen in proximal aortic dissection have been made to demonstrate its feasibility in selected patients, but applicability is limited (6,7).…”