Endovascular repair of the ascending aorta in patients at high risk for open repair

Abstract

Objective: Although endovascular repair has been widely adopted for treatment of descending thoracic aortic pathologies, its role in ascending aortic pathologies remains undefined. We reviewed our experience with endovascular repair of ascending aortic pathologies in patients facing high or prohibitive risk with open surgical treatment.

Methods: From 2007 to 2013, 6 patients (aged 16-90 years) underwent endovascular repair (pseudoaneurysm, n = 4; acute type A aortic dissection, n = 2). Their records were retrospectively reviewed.

Results: All patients had extensive comorbidities or anatomic features making an open surgical approach high risk. Three cases were done on an emergency basis (aortic dissection, n = 2; ruptured pseudoaneurysm, n = 1). Ascending aortic access was obtained through transapical (n = 4), transfemoral (n = 1), and left common carotid artery (n = 1) approaches. Cook Zenith TX2 (n = 4), Cook EVAR iliac limb (n = 1), and Amplatzer occluder (n = 1) devices were used, with 3 patients requiring more than 1 stent-graft. Stent-graft lengths ranged from 55 to 81 mm; diameters ranged from 22 to 40 mm. Technical success was achieved in 5 cases (83%); 1 patient (type A dissection) had an intraoperative endoleak not amendable to further endovascular repair. In-hospital and 30-day mortalities were zero. One patient sustained a minor stroke, which reversed completely. Stay ranged from 5 to 15 days. On follow-up, 1 patient (type A dissection) had an endoleak at 12 months. Two patients died of nonaortic causes at 6 and 27 months after endovascular repair.

Conclusions: Endovascular repair of ascending aortic pathology is feasible in patients facing high risk with open surgery, with promising early results. Technical challenges remain in adapting current endovascular technology to ascending aortic pathologies, particularly type A aortic dissection.