Supervisors info:
Γεώργιος Γερουλάκος, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Ιωάννης Κακίσης, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Αχιλλέας Χατζηιωάννου, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Summary:
Objective: surgery remains the treatment of choice in ascending aortic diseases. However, many patients are considered at high or prohibitive risk for open surgery with sternotomy and the use of extracorporeal circulation. Endovascular treatment is a relatively new technique used as alternative management of these patients, but without formal indications, guidelines, or fully standardized techniques. Additionally, there are significant anatomical and technical challenges in its application due to the short length and curvature of the ascending aorta, proximity to the aortic valve, the coronary arteries, and the anonymous artery, and the hemodynamic forces of the cardiac ejection. The purpose of this study was to gather the limited and fragmented knowledge from the literature and to clarify the indications, limitations, capabilities of technology and the necessary preparation for the application of transcatheter techniques in the ascending aorta.
Material and method: a systematic review of the literature on the endovascular repair of ascending aortic diseases was performed. Publications of case reports or small series (≤ 4 patients) as well as hybrid techniques were not included. A study was also performed on all patients with ascending aortic disease treated surgically at the Attikon Hospital in the last decade, who were reviewed in a prospective database for their potential suitability for endovascular treatment as an alternative to open surgery.
Results: a total of 15 retrospective studies were identified, including 192 patients unsuitable for surgery who were treated with endovascular techniques due to type A dissection (64.5%), pseudoaneurysm (18.2%), aneurysm (7.8%) and other indications. A large percentage of them (67.7%) had a history of cardiac surgery. The anatomical criteria included landing zones ≥ 10mm in length and < 44mm in diameter, a distance of the neck or the intimal tear > 10mm distal to the sinotubular junction and > 5mm proximally to the innominate artery. Femoral arterial access was used in 72.6% of patients. Seventeen different aortic endografts of various designs were used, of which only 2 were made specifically for the ascending aorta. Usually, a 10-20% larger endograft size was selected, except for the acute dissections where oversizing was 0-10%. Rapid ventricular pacing was the most common technique for reducing cardiac output. Hospital and late mortality were 10.4% and 18.6% respectively. Type I endoleaks (11.4%) and CVAs (8.8%) were the most common complications. Kinking, migration, or infection of the endograft occurred in 3.6% of patients. Complications of these ascending aorta-specific techniques, involving the apex of the left ventricle, the coronary arteries, and the aortic valve were noticed in 9.8% of cases. Conversion to open surgery or reintervention was necessary for 2.6% and 2% of patients respectively. In the study of the operated patients in the Attikon hospital, it was found that only a few (10%) met the anatomical and no one the clinical criteria for possible endovascular treatment, mainly due to many concomitant diseases that needed surgical correction.
Conclusions: Endovascular techniques are an evolving alternative treatment for patients deemed unfit for open surgery and have been shown to be salvage in selected patients with life-threatening diseases of the ascending aorta. The occurrence of possible serious complications requires these techniques to be performed by a multidisciplinary team, in a hybrid operating room environment with the capability of immediate open conversion and use of extracorporeal circulation. Creating a registry and conducting prospective randomized trials will be necessary for the future to record the long-term course of these techniques and to compare conservative, endovascular, and surgical treatment in ascending aortic diseases.
Keywords:
Ascending aortic diseases, Endovascular ascending aorta repair, Endovascular techniques, Ascending aorta stenting, Zone 0 TEVAR
