Wrapping of the ascending aorta revisited—is there any role left for conservative treatment of ascending aortic aneurysm?

Abstract

Dilatation of the ascending aorta (AA) is a common finding in patients with aortic valve disease.The clinical practice guidelines recommend replacing the AA whenever the diameter exceeds 45 mm.However, no consensus has been reached regarding the approach when the aorta is only moderately dilated.Although the risk in aorta replacement is generally low, it may be higher when associated with other complex surgical procedures or it is carried out in elderly patients or patients with significant comorbidity. This would justify the use of alternative surgical techniques, which reduce surgical risk and guarantee a durable correction of the aortic pathology. Conservative treatment of aneurysms of the AA via wrapping with different synthetic materials has been implemented for many years. The most commonly used technical variant is wrapping the dilated aorta with a vascular prosthesis with a predetermined diameter. When this technique is adequately applied, it immediately reduces the diameter of the AA and, to a lesser degree, the diameter of the aortic root and arch, while at the same time it reinforces the weak aortic wall. These effects lead to a drop-in wall shear stress and in the risk of aortic dissection and rupture, and persist over time. Although the low elasticity of the external support causes significant changes in the histologic structure of the aortic wall, mainly atrophy and alterations typical of a foreign body-induced reaction, this does not seem to involve a higher risk of complications. In some selected patients, this technique may be used in cases other than post-stenotic aortopathy, and also in aortas with a larger diameter.

Challenging corrective redo surgery in a patient presenting with severe aortic redilatation following an aortic root reduction aortoplasty with concomitant external wrapping

“…3 Studies in this area have only considered external wrapping in patients who had on average mild-tomoderate dilation of the ascending aorta; they report good outcomes. 3 In our patient, the aortic root was originally severely dilated. This case, therefore, questions the safety of carrying out the controversial aortic external wrapping procedure in aortas that are largely aneurysmal, even if concomitant reduction aortoplasty is also performed.…”

“…In contemporary literature, little has been written about the complications of aortic external wrapping . Studies in this area have only considered external wrapping in patients who had on average mild‐to‐moderate dilation of the ascending aorta; they report good outcomes .…”

Wrapping of ascending aortic aneurysm with supra‐aortic debranching and endovascular repair for aortic arch aneurysm and ruptured descending thoracic aortic aneurysm

“…It is usually performed by resecting a longitudinal stripe of the aorta and resuturing the edges. External wrapping graft is also an attractive option that has been explored . It is associated with less bleeding, lower chances of acute kidney injury and strokes …”

53-Year-Old Man With Progressive Dyspnea and Orthopnea

“…7 Wrapping with polyester mesh is only appropriate for moderate-sized aortic aneurysms, not dissected aortas. 10 Intravenous esmolol and nitroglycerin were administered in the ICU for heart rate and blood pressure control, and the patient underwent cardiovascular surgery consultation. He was subsequently treated with an aortic valve resuspension, ascending aortic replacement with a 28-mm Dacron graft, proximal descending thoracic aorta stenting, total arch replacement with 26-mm Dacron graft, implantation of the arch vessels off the aortic arch graft with grafting of the left common carotid, left subclavian, and innominate arteries.…”