Thoracic endovascular aortic repair for the ascending aorta: experience and pitfalls

Abstract

Thoracic endovascular aortic repair (TEVAR) of the ascending aorta is a developing alternative treatment strategy, which currently is specifically aimed at patients who are too high risk for open surgery. TEVAR has been applied to patients with a variety of pathologies of the ascending aorta including type A dissection, intramural hematoma (IMH), penetrating ulcers, aneurysm and pseudoaneurysm. Here we discuss the current evidence regarding the use of TEVAR for the ascending aorta as well as the latest techniques and pitfalls of the procedure. The challenges of this modality are considerable, and the techniques that have been applied draw from the many facets of endovascular experience. There is limited literature regarding the use of stent grafts in the ascending aorta, and the pool of patients currently considered appropriate candidates for the procedure is small. This is an evolving intervention that warrants further study and the development of devices specifically engineered to meet the anatomical and physiologic challenges of the ascending aorta.

Keywords: Thoracic endovascular aortic repair (TEVAR); ascending aorta; cardiac surgery; endovascular.

Figure 1

Pre-operative axial (A) and 3D reconstruction (B) CTA images demonstrating large mycotic ascending aortic anastomotic pseudoaneurysm (white arrow) in a 35-year-old male who had undergone previous orthotopic heart transplant.

Figure 2

Curved planar reformats with centerline reconstruction of the ascending aorta from the 3D CTA with corresponding measurements of landing zone diameters and centerline and greater curvature lengths. CTA, computed tomography angiography.

Figure 3

Intraoperative completion angiogram following successful deployment of the CTAG device in the ascending aortic position.

Figure 4

Follow up axial (A) and 3D reconstruction (B) CTA imaging status-post TEVAR of the ascending aorta demonstrating complete resolution of the mycotic pseudoaneurysm with no endoleak. CTA, computed tomography angiography.

Figure 5

Pre (A) and post (B) deployment angiograms of a single side-branched endograft used to treat a saccular chronic post-traumatic transverse arch pseudoaneurysm in a high-risk patient following extra-thoracic cervical arch debranching. Follow up 3D CTA reconstruction (C) demonstrating widely patent right carotid-left subclavian bypass with endovascular occlusion plug in proximal left subclavian artery and well positioned aortic and side branch endografts without endoleak. CTA, computed tomography angiography.