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Editorial
. 2019 Jul;8(4):500-508.
doi: 10.21037/acs.2019.07.06.

Art of operative techniques: treatment options in arch penetrating aortic ulcer

Chiara Lomazzi  1 , Viviana Grassi  1 , Maurizio Domanin  1   2 , Carlo De Vincentiis  3 , Gabriele Piffaretti  4 , Santi Trimarchi  1   2
Affiliations
Editorial

Art of operative techniques: treatment options in arch penetrating aortic ulcer

Chiara Lomazzi et al. Ann Cardiothorac Surg. 2019 Jul.

Abstract

Penetrating aortic ulcer (PAU) of the arch has a focal extent which often represents an adequate anatomic target for thoracic endovascular aortic repair (TEVAR). However, the anatomic constraints represented by the supra-aortic vessels pose either clinical or technical challenges that increase when the PAU develops proximally in the arch. Currently, different types of endografts are commercially available and have been used to treat aortic arch lesions. These include branched/fenestrated endografts for a total endovascular approach, and standard devices that can be used in combination with open/hybrid surgical operations, with the aim to exploit the minimally invasive nature of TEVAR by extending the proximal landing zone when necessary. We describe several current techniques adopted in such settings.

Keywords: Penetrating aortic ulcer (PAU); hybrid aortic arch repair; surgical options; thoracic endovascular aortic repair (TEVAR).

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Conflict of interest statement

Conflicts of Interest: Dr. Trimarchi is speaker and consultant for Gore (W.L. Gore; Flagstaff, AZ, USA) and Medtronic (Medtronic, Inc.; Minneapolis, MN, USA).

Figures

Figure 1
Figure 1
Penetrating aortic ulcer (PAU) of the left hemiarch which requires proximal TEVAR deployment in Ishimaru zone 2. TEVAR, thoracic endovascular aortic repair.
Figure 2
Figure 2
Hybrid and total endovascular techniques for treating PAU which require TEVAR in landing zone 2. (A) Endograft deployment in Ishimaru zone 2 with surgical carotid-subclavian bypass graft and retrograde plug embolization of the LSA. A vascular plug is positioned proximally to the origin of LVA. (B) LSA preservation using the parallel grafts technique. (C) Scallop device for LSA preservation. TEVAR in zone 2 with in situ fenestration for preserving LSA. This technique includes the use of (D) laser catheter for fenestration (E), balloon dilatation and (F) stent positioning. PAU, penetrating aortic ulcer; TEVAR, thoracic endovascular aortic repair; LSA, left subclavian artery; LVA, left vertebral artery.
Figure 3
Figure 3
Access for endograft delivery: prosthetic conduit using the iliac artery as an alternative when percutaneous approach is not possible for small and hostile femoral arteries.
Figure 4
Figure 4
Penetrating aortic ulcer (PAU) of the inner curve of the aortic arch which requires proximal TEVAR deployment in Ishimaru zone 1. TEVAR, thoracic endovascular aortic repair.
Figure 5
Figure 5
Hybrid and total endovascular techniques for treating PAU which require TEVAR in landing zone 1. (A) Single branched endograft (Gore® TAG® thoracic branched endoprosthesis from W.L. Gore®. (B) Endograft deployment in landing zone 1 with surgical carotid-to-carotid bypass and left carotid-LSA bypass grafts plus plug embolization of the LSA. (C) Double parallel technique using a covered stent for the left common carotid artery. The LSA and TEVAR completion is shown. PAU, penetrating aortic ulcer; LSA, left subclavian artery; TEVAR, thoracic endovascular aortic repair.
Figure 6
Figure 6
Hybrid and total endovascular techniques for treating PAU which require TEVAR in landing zone 0. (A) Penetrating aortic ulcer (PAU) of the inner curve of the aortic arch which requires proximal TEVAR deployment in Ishimaru zone 0. (B) Double branched Relay NBS® Plus (Terumo Aortic; Tokyo, Japan). (C) Fenestrated endograft Najuta (Kawasumi Inc.; Tokyo, Japan). (D) Type I “hybrid” aortic arch. TEVAR, thoracic endovascular aortic repair.
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References

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