Endovascular repair of the ascending aorta, a single center experience in emergent and elective cases

S. Mosbahi¹, J. Bavaria², W. Szeto³, M. Berezowski³, J. J. Kelly³, f. jiang³, B. Cannon³, N. J. Goel³, w. grace⁴, N. D. Desai^3
1University of Pennsylvania Health System, Philadelphia, Pennsylvania ²Hospital of the University of Pennsylvania, Dept. of Cardiovascular S, Philadelphia, Pennsylvania ³University of Pennsylvania, Philadelphia, Pennsylvania ⁴Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania

Purpose: TEVAR as the primary treatment for conditions affecting the descending aorta has been widely accepted. Considering anatomical challenges inherent to zone 0, this technique is still in development for ascending pathologies. Further exploration is needed regarding optimal access, prosthesis, and the identification of patients who would benefit from this procedure.

Methods: The charts of 16 patients who underwent ascending TEVAR between 2009 and 2023 at a single institution were retrospectively reviewed, considering the indication, the access, the type of prosthesis implanted, and their postoperative outcomes. Nine cases were elective procedures (pseudoaneurysms following other cardiac operations), and seven were emergent cases (5 Type A aortic dissections and 3 Type A aortic intramural hematomas). The patients are presented in Table 1.

Results: There was no significant difference in age between the two groups: urgent: 80.1±10.1, elective: 72.6±10.6-year-old, p= 0.18. Mean follow-up of hospital survivors was 2.6±3.4 years. All patient from the elective group and one from the urgent group had prior cardiac/aortic surgeries. All patients had extensive comorbidities. The most common access was through the ilio-femoral axis (N=10), followed by transapical (N=5) or axillary (N=1) access. All elective cases were discharged home, whereas a patient of the urgent group died of aortic rupture during the procedure. Imaging follow-up was complete in 14/16 patients and there were 2 endoleaks type Ia that remained stable during follow-up. Late death could not be attributed to an aortic etiology in 6/7 patients that died during follow-up, the cause of death was unknown in the remaining patient.
Table 1 summarizes the 16 cases.
Figure 1 illustrates an elective case of endovascular ascending aortic repair of pseudoaneurysm. Preoperative computed tomography angiography (CTA), intraoperative aortogram and postoperative CTA, (patient highlighted in yellow in table 1).

Conclusion: TEVAR of the ascending aorta is still an emerging procedure which can be performed safely in selected patient deemed too high-risk for open surgery in an elective setting. Emergent ascending TEVAR in the case of acute aortic syndrome is a valid alternative in high-risk patient with encouraging early outcomes. Development of a dedicated composite device of ascending stentgraft and aortic root endoprosthesis (endo-Bentall) might be the last step towards an increase in the application of this strategy.

Identify the source of the funding for this research project: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.