A ruptured penetrating atherosclerotic ulcer of the ascending aorta: a case report of an endovascular repair with extending the length of the aortic coverage by debranching the innominate artery

Transapical to Femoral Through-and-Through Wire Technique for Ruptured Aortic Arch Aneurysm Management: Case Report and Review of Literature

AIM

To present a case where the transapical and femoral accesses were used to establish a through-and-through guidewire to deliver branched arch endograft effectively.

CASE

An 86-year-old male presented with an aortic arch aneurysm rupture was treated with branched arch endograft. Due to tortuous anatomy, several attempts using femoral and axillary routes to navigate the endograft to the proximal landing zone failed. A through-and-through guidewire was established using transapical and femoral accesses to provide sufficient stability for subsequent advancement and delivery of the arch branch endograft.

CONCLUSION

Transapical to femoral through-and-through approach is a feasible adjuvant for delivering aortic endografts in emergent cases, particularly in patients with trackability issues and challenging tortuous anatomy. This technique could be a valuable solution for carefully selected patients where conventional approaches are not viable.

CLINICAL IMPACT

Transapical access has been widely used in valvular and elective aortic interventions; however, its application in ruptured scenarios is seldom documented. This case report details the utilisation of transapical access in a ruptured aortic arch aneurysm with a tortuous aorta, where femoral and axillary access have proven inadequate. Establishing a transapical to transfemoral through-and-through wire has provided enhanced stability for precise endograft deployment. Procedural details and outcomes, alongside a review of the literature, underscore the use of transapical access and through-and-through wire in managing complex ruptured pathologies, addressing gaps in the literature concerning its efficacy and safety in urgent high-risk scenarios.

Minimally Invasive Endovascular Repair for Nondissected Ascending Aortic Disease: A Systematic Review

Objective

The aim of this study is to evaluate the efficacy of endovascular treatment for nondissected diseases of the ascending aorta. Data Sources. PubMed, Embase, and SciELO. Review Methods. In this study, we conducted a search on the PubMed, Embase, and SciELO databases for all cases of ascending aortic endovascular repair included in the literature published between January 2007 and July 2023, excluding type A aortic dissection. We reviewed 56 case reports and 7 observational studies included in this study, assessing the techniques, equipment, procedural steps, and results. We summarized the age, complications, follow-up time, and access route.

Results

This study includes 63 articles reporting 105 patients (mean age: 64.96 ± 17.08 years) who received endovascular repair for nondissected ascending aortic disease. The types of disease include aneurysm (N = 16), pseudoaneurysm (N = 71), penetrating aortic ulcer (N = 10), intramural hematoma (N = 2), thrombosis (N = 2), iatrogenic coarctation (N = 1), and rupture of the aorta (N = 3). The success rate of surgery is 99.05% (104/105). Complications include endoleak (10.48%, 11/105), stroke (5.71%, 6/105), postoperative infection (1.91%, 2/105), acute renal failure (0.95%, 1/105), aortic rupture (0.95%, 1/105), thrombosis (0.95%, 1/105), and splenic infarction (0.95%, 1/105). Five patients required conversion to open surgery, two patients underwent endovascular reintervention, and four of these five patients underwent surgery due to endoleak. Early mortality was 2.86% (3/105).

Conclusion

While the viability and results of endovascular repair for the treatment of ascending aortic disease are acknowledged in some circumstances, further research is needed to determine the safety and effectiveness of endovascular treatment for ascending aortic disease.

The Management of Penetrating Aortic Ulcer

Penetrating aortic ulceration (PAU) is part of the spectrum of acute aortic syndromes (AAS), and is defined as an ulcerated intimal disruption due to atherosclerotic disease. PAU may be simple, isolated and asymptomatic, or it may be symptomatic, aneurysmal and extensive; these may progress and lead to rupture. This review aims to evaluate the treatment options for PAU. Treatment options range from radiological surveillance, risk factor modification, best medical therapy and open or endovascular surgical repair. Patients with PAU are frequently older and comorbid with relatively damaged aortic tissue; this can make open surgical repair more challenging. Endovascular repairs for larger, symptomatic, aneurysmal PAU may be performed with acceptable outcomes. Complex endovascular repairs may be required depending on the pathology. Patients with small, asymptomatic, uncomplicated PAU may be safely followed up with surveillance. PAU with concomitant intramural haematoma (IMH) should be closely monitored to observe for resolution or progression following conservative and medical management strategies. PAU is a unique entity and its natural history should be studied independently to better understand appropriate management strategies. This research is currently lacking, and larger studies or registries may be helpful in optimising PAU management.