Arch and access vessel complications in penetrating aortic ulcer managed with thoracic endovascular aortic repair

Abstract

Background: To analyze our experience and to describe access and arch-related challenges when performing thoracic endovascular aortic repair (TEVAR) for penetrating aortic ulcers (PAUs).

Methods: This is a single-center, observational, cohort study. Between October 2003 and February 2019, 48 patients with PAU were identified; 37 (77.1%) treated with TEVAR were retrospectively analyzed. Primary major outcomes were early (<30 days) and late survival, freedom from aortic-related mortality (ARM), and a composite endpoint of arch/vascular access-related complications.

Results: On admission, 17 (45.9%) patients were symptomatic with 4 (10.8%) presenting with rupture. In-hospital mortality was 8.1% (n=3). We observed 10 (27.0%) arch/access-related complications. There were 4 (10.8%) arch issues: 2 transient ischemic attacks and 2 retrograde acute type A dissections which required emergent open conversion for definitive repair. Access issues occurred in 6 (16.2%) patients: 3 (8.1%) required common iliac artery conduit, and 1 (2.7%) patient required iliac artery angioplasty to deliver the stent-graft. In addition, 2 (5.4%) patients developed access complications which required operative repair [femoral patch angioplasty (n=2), and femoral pseudoaneurysmectomy (n=1)]. Arch/access-related mortality rate was 5.4% (n=2) and median follow-up was 24 (range, 1-156; IQR, 3-52) months. Estimated survival was 87.1% (standard error: 0.6; 95% CI: 71.2-84.9%) at 1 year, and 63.3% (SE: 0.9; 95% CI: 44.1-79%) at 4 years. Estimated freedom from reintervention was 88.9% (SE: 0.5; 95% CI: 74.8-95.6%) at 1 year, and 84.2% (SE: 0.7; 95% CI: 67.3-93.2%) at 4 years. No arch/access-related issues developed during the follow-up period.

Conclusions: Our experience confirms that vascular access and aortic arch issues are still a challenging aspect of performing TEVAR for PAUs. Our cumulative 27% rate of access/arch issues is lower than previously reported due to both technological advancements and meticulous management of both access routes and arch anatomy.

Keywords: Thoracic penetrating aortic ulcers (thoracic PAUs); access complications; retrograde type A dissection; stroke after thoracic endovascular aortic repair (stroke after TEVAR).

Figure 1

Preoperative CTA with volume rendering 3D reconstruction (A) of a distal aortic arch PAU. Calcifications (dotted arrow) are typically present at the edges of the ulcer. Axial image (B) shows the measurements of the ulcer: diameter (Ø), depth (D), and length (L). PAU, penetrating aortic ulcer.

Figure 2

Two cases of PAU of the distal aortic arch (A,B) and of the descending thoracic aorta (C,D,E,F). Axial images (A1-A3) show the enlargement evolution of a “blister-like” lesion over a 2-year period. Volume rendering 3D reconstructions show, preoperatively (B1), the location and the typical calcifications surrounding focally only the aorta affected by the PAU. Postoperatively (B2) the result of TEVAR after 24 months follow-up with the complete exclusion of the lesion, and the good apposition of the SG at the inner curve in such a Romanesque aortic arch. Preoperative CTA of a contained rupture (C) of a descending PAU with the typical calcifications of the entire aorta (D). Volume rendering 3D reconstructions of the same case: preoperative (E) and postoperative (F) after 12 months of follow-up. PAU, penetrating aortic ulcer; TEVAR, thoracic endovascular aortic repair.

Figure 3

Consort diagram indicating all descending and thoracoabdominal aneurysm patients during the period of study, including the patient population from which this series was derived. DTA, descending thoracic aneurysm; TAAA, thoraco-abdominal aortic aneurysm; TBAD, type B aortic dissection; IMH, intramural hematoma; PAU, penetrating aortic ulcer.

Figure 4

A case of “giant” PAU of the hiatus (A) with the typical calcification at the edge of the ulcer (A1) clearly visible at the preoperative volume rendering 3D reconstruction. Follow-up CTA at 36 months shows the complete shrinkage of the lesion after plug embolization of the celiac trunk (B, dotted arrow) and TEVAR with intentional overstenting of the celiac trunk and distal landing zone at the superior boarder of the superior mesenteric artery (B1). PAU, penetrating aortic ulcer; TEVAR, thoracic endovascular aortic repair.

Figure 5

Kaplan-Meier estimates of the overall survival (A) and freedom from ARM (B). ARM, aortic-related mortality.