Endovascular ascending aortic repair in type A dissection: A systematic review

Editor's Choice - Outcomes of Endovascular Repair Confined to the Ascending Thoracic Aorta: A Systematic Review and Meta-Analysis

OBJECTIVE

High risk, inoperable patients with ascending aortic disease are increasingly managed with thoracic endovascular aortic repair (TEVAR). The aim of this study was to assess the available literature on TEVAR confined to the ascending aorta (a-TEVAR), describing study and patient characteristics, procedural and stent graft details, and outcomes.

DATA SOURCES

This was a systematic review and meta-analysis. MEDLINE, Web of Science, and Scopus were systematically searched for eligible studies reporting on outcomes after a-TEVAR (PROSPERO ID: CRD42023440826). Eligible studies reported outcomes after a-TEVAR without adjunctive supra-aortic vessel treatment.

REVIEW METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed. The ROBINS-I and Joanna Briggs Institute Critical Appraisal Checklist were used as quality assessment tools. A Grading of Recommendations Assessment, Development, and Evaluation (GRADE) evidence certainty analysis was performed for the main outcomes. The main outcome was death. A proportional meta-analysis was performed with a mean and 95% confidence interval (CI) for the main outcomes. All articles were included up to 1 January 2024.

RESULTS

Ninety four studies were included (19 cohort studies, 75 case reports or series), reporting on 259 patients (57.8% male). The mean age was 69.1 (95% CI 65.0 - 73.1) years and mean follow up 19.6 (95% CI 14.5 - 24.6) months. The most common comorbidity was prior cardiac or thoracic surgery (n = 191). The most frequent indications for a-TEVAR (52.1% urgent a-TEVAR) were type A aortic dissection (43.6%) and pseudoaneurysm (38.6%). The most commonly deployed stent grafts were Gore (44.5%), Cook (23.5%), and Medtronic (17.0%). The in hospital mortality rate was 7.3% (95% CI 4.7 - 11.2%), 30 day mortality rate 7.7% (95% CI 5.1 - 11.6%), and overall mortality rate 17.0% (95% CI 12.9 - 22.0%) during follow up. GRADE showed very low evidence certainty for all outcomes. Eighty eight complications were reported and there was a re-operation rate of 13.1% (95% CI 9.5 - 17.8%). In hospital and 30 day mortality rates for type A dissection were 12.4% (95% CI 7.5 - 19.7%) (n = 14) and 13.3% (95% CI 8.2 - 20.8%) (n = 15), respectively, and for pseudoaneurysm 4.0% (95% CI 1.6 - 9.8%) (n = 4) and 4.0% (95% CI 1.6 - 9.8) (n = 4), respectively.

CONCLUSION

Despite heterogeneous literature and very low GRADE evidence certainty, a-TEVAR seems technically feasible in high risk patients. In addition, there is need for a consensus on when and how to use a-TEVAR and a need for a specific endograft for use in the ascending aorta.

From zone 1 to zone 3: Feasibility and safety of complex endovascular aortic repairs in type A aortic dissection

OBJECTIVE

More than 30% of patients presenting with acute type A aortic dissection are considered high risk or inoperable. This study aims to investigate the early and midterm outcomes of complex endovascular aortic repair of aortic root, ascending aorta, and aortic arch among patients with acute type A aortic dissection.

METHODS

From January 2018 to January 2023, 29 patients who were considered high risk for open operation underwent endovascular aortic repair. Patients were considered high risk because of frailty (n = 14), severe malperfusion (n = 5), chronic obstructive pulmonary disease and on home oxygen (n = 4), frozen chest (n = 3), metastatic cancer (n = 3), ejection fraction <20% (n = 4), and cirrhosis (n = 2). For an isolated tear in the ascending aorta (zone 0), ascending stent graft placement was performed using commercially available aortic stent grafts. For patients with a tear in the aortic root, Endo-Bentall was performed using a physician-modified modular device composed of a self-expanding transcatheter aortic valve incorporated inside an aortic stent graft. For patients with a tear in the ascending aorta as well as the aortic arch (zone 0, zone 1, 2), ascending stent graft placement and endovascular arch repair was performed. Follow-up electrocardiogram-gated computed tomography was performed to evaluate aortic remodeling.

RESULTS

The mean age for this cohort was 76.3 ± 11.1 years. Endovascular repairs included isolated ascending stent placement in 65.5% (19/29), endo-Bentall in 6.9% (2/29), endo-Bentall plus endo arch in 6.9% (2/29), and ascending thoracic endovascular repair + endo arch in 20.7% (6/29). The operative mortality was 10.3% (3/29). Stroke rate was 10.3% (3/29). During the follow-up time of a median of 6.25 months (range, 0.85-64.6 months), an endoleak was observed in 42.3% (11/26) patients (80% among patients with a tear <2 cm of sinotubular junction). Seven patients had a type 1a endoleak, whereas 4 patients had a type 1b endoleak on follow-up computed tomography angiography. Three patients required reintervention. The Kaplan-Meier 5-year probability of survival for the entire cohort post-intervention was 35%.

CONCLUSIONS

Early outcomes of complex endovascular repair of ascending aortic dissection are promising with acceptable mortality and stroke rate. However, the rate of endoleak after isolated ascending thoracic endovascular repair with a tear within 2 cm of the aortic root is high with poor long-term survival.

Current techniques of repair of aortic arch pathologies and the role of the aortic team

The treatment of aortic arch pathologies is becoming progressively more complex and multidisciplinary. Despite progresses in open surgical techniques, the high rate of surgical morbidity and mortality, especially in frail and elderly patients, has led to the development of alternative treatment options to conventional open surgery such as hybrid and endovascular procedures. Our purpose is to summarize the advantages and disadvantages of the different approaches and investigate the role of a dedicated aortic team in the choice of the most appropriate treatment for each patient.

Sex-Specific Morphometric Analysis of Ascending Aorta and Aortic Arch for Planning Thoracic Endovascular Aortic Repair: A Retrospective Cohort Study

OBJECTIVE

In many studies on aortic disease, women are underrepresented. The present study aims to assess sex-specific morphometric differences and gain more insight into endovascular treatment of the ascending aorta (AA) and arch.

METHODS

Electrocardiogram-gated cardiac computed tomography scans of 116 consecutive patients who were evaluated for transcatheter aortic valve replacement were retrospectively reviewed. Measurements of the AA and aortic arch were made in multiplanar views, perpendicular to the semi-automatic centerline. Multiple linear regression analysis was performed to identify predictors affecting AA and aortic arch diameter in men and women. Propensity score matching was used to investigate whether sex influences aortic morphology.

RESULTS

In both sexes, body surface area (BSA) was identified as a positive predictor and diabetes as a negative predictor for aortic diameters. In men, age was identified as a positive predictor and smoking as a negative predictor for aortic diameters. Propensity score matching identified 40 pairs. Systolic and diastolic mean diameters and AA length were significantly wider in men. On average, male aortas were 7.4% wider than female aortas, both in systole and diastole.

CONCLUSIONS

The present analysis demonstrates that, in women, increased BSA is associated with increased aortic arch diameters, while diabetes is associated with decreased AA and arch diameters. In men, increased BSA and age are associated with increased AA and arch diameters, while smoking and diabetes are associated with decreased AA and arch diameters. Men were confirmed to have 7.4% greater AA and arch diameters than women.

CLINICAL IMPACT

Men had 7.4% greater ascending aorta and arch diameters than women in a retrospective cohort, gated computed tomography-based study of 116 patients. Sex-specific differences in ascending aortic and arch size should be considered by aortic endovascular device manufacturers and physicians when developing ascending and arch endografts and planning aortic interventions.

Feasibility and safety of Stanford A aortic dissection complete endovascular repair system in a porcine model

BACKGROUND

Acute type A aortic dissection (ATAAD) is a catastrophic disease with high morbidity and mortality. Although open surgery is still the gold standard for the treatment of ATAAD, some patients, with advanced age and multiple comorbidities, can only receive medical management alone. Nowadays, thoracic aortic endovascular repair (TEVAR) provides a potential treatment option for the patient with ATAAD, but traditional stent grafts (SGs), which are not designed for the ATAAD, are inapplicable to the unique anatomy of the aortic arch. Therefore, we innovatively created the BRIDGE system (Chuangxin Medical, Shenzhen, China), a complete endovascular reconstruction system designed to treat ATAAD. This study aimed to evaluate the feasibility and safety of the novel Stanford A aortic dissection complete endovascular reconstruction system in a porcine model.

METHOD

The BRIDGE system consists of the type A stent system and the type C stent system. Between November 2020 and March 2021, three white swine were utilized in the study. The BRIDGE system was deployed via the transcatheter approach under angiographic guidance. The swine(n = 3) treated with our system were evaluated using angiography before sacrifice 1-month after implantation, which was followed by gross specimen evaluation and histological examination of harvested tissues.

RESULT

The acute procedure success rate was 100% (3/3). The immediate post-procedural angiography showed that both type A SGs and type C SGs were deployed in satisfactory locations, with patency of the supra-aortic trunk and no endoleak. The cumulative mortality of 30-day was 0% without any adverse events. No device migration or leakage was observed angiographically, before sacrifice. The gross observation confirmed a type A SG covered part of the entry of anonyma. Favorable endothelialization, no thrombogenesis, and slight inflammatory infiltration of the tissues around the device were confirmed by microscopic examinations in all pigs.

CONCLUSION

It was feasible and secure to use Stanford A aortic dissection complete endovascular reconstruction system to implement a transcatheter endovascular repair in a porcine model. With this novel system, treating acute type A aortic dissection may be more efficient and secure in human.

Feasibility of Total Endovascular Repair of the Aorta in Patients with Acute Type A Aortic Dissection: Morphological Analysis of 119 Patients

(1) Background: This study aimed to morphologically analyze acute type A aortic dissection (aTAAD) patients for potential endovascular treatment candidates. The objective was to specify requirements for aTAAD endovascular devices. (2) Methods: A single-center retrospective analysis included aTAAD patients who underwent open surgical repair between November 2005 and December 2020. Preoperative CTA scans were used for morphological analysis, assessing endovascular repair eligibility. Statistical tests were performed. (3) Results: A total of 129 patients with aTAAD were studied, with 119 included. Entry tear (ET) locations were identified, mainly in the aortic root, 20 mm above the sinotubular junction (STJ) and within the ascending aorta (20 mm above STJ to -20 mm before the brachiocephalic trunk). Endovascular treatment was deemed feasible for 36 patients, with suggested solutions for the aortic arch and descending aorta. Significant differences were observed between eligible and noneligible groups for aortic diameter, false lumen diameter, distance between STJ and entry tear, and more. Dissection extension showed no significant difference. (4) Conclusions: Morphological analysis identified potential aTAAD candidates for endovascular treatment, highlighting differences between eligible and noneligible morphologies. This study offers insights for implementing endovascular approaches in aTAAD treatment and emphasizes the need for research and standardized protocols.

Endovascular Intervention for Aortic Dissection Is "Ascending"

Ascending aorta diseases represent an important cause of mortality worldwide. Notably, acute and chronic thoracic aorta pathologies have increased during the last years, but medical therapy does not seem to influence their natural history. Currently, although open surgery is the first choice of treatment, many patients are still rejected or have poor outcomes. In this scenario, endovascular treatment is raised as a valuable option. In this review we describe the limitations of conventional surgery and the state-of-art of endovascular ascending aorta repair.

Acute aortic syndromes: An internist's guide to the galaxy

Acute aortic syndromes (AASs) are severe conditions defined by dissection, hemorrhage, ulceration or rupture of the thoracic aorta. AASs share etiological and pathophysiological features, including long-term aortic tissue degeneration and mechanisms of acute aortic damage. The clinical signs and symptoms of AASs are unspecific and heterogeneous, requiring large differential diagnosis. When evaluating a patient with AAS-compatible symptoms, physicians need to integrate clinical probability assessment, bedside imaging techniques such as point-of-care ultrasound, and blood test results such as d-dimer. The natural history of AASs is dominated by engagement of ischemic, coagulative and inflammatory pathways at large, causing multiorgan damage. Medical treatment, multiorgan monitoring and outcome prognostication are therefore paramount, with internal medicine playing a key role in non-surgical management of AASs.

Aortic Dissection

Acute aortic dissection is a highly morbid condition with high mortality that requires emergent surgical evaluation and repair. The intraoperative management of acute aortic dissection requires the anesthesiologist to do far more than administer anesthesia and begins before the patient arrives at the operative theater. High-fidelity communication with the surgeon, knowledge of the surgical plan, knowledge of the anatomy of the dissection, and a nuanced understanding of aortic dissection pathophysiology are all critical aspects of anesthetic management.

Coronary artery involvement in type A aortic dissection: Fate of the coronaries

BACKGROUND

Type A aortic dissection (TAAD) involves a tear in the intimal layer of the thoracic aorta proximal to the left subclavian artery, and hence, carries a high risk of mortality and morbidity and requires urgent intervention. This dissection can extend into the main coronary arteries. Coronary artery involvement in TAAD can either be due to retrograde extension of the dissection flap into the coronaries or compression and/or blockage of these vessels by the dissection flap, possibly causing myocardial ischemia. Due to the emergent nature of TAAD, coronary involvement is often missed during diagnosis, thereby delaying the required intervention.

AIMS

The main scope of this review is to summarize the literature on the incidence, mechanism, diagnosis, and treatment of coronary artery involvement in TAAD.

METHODS

A comprehensive literature search was performed using multiple electronic databases, including PubMed, Ovid, Scopus and Embase, to identify and extract relevant studies.

RESULTS

Incidence of coronary artery involvement in TAAD was seldom reported in the literature, however, some studies have described patients diagnosed either preoperatively, intraoperatively following aortic clamping, or even during autopsy. Among the few studies that reported on this matter, the treatment choice for coronary involvement in TAAD was varied, with the majority revascularizing the coronary arteries using coronary artery bypass grafting or direct local repair of the vessels. It is well-established that coronary artery involvement in TAAD adds to the already high mortality and morbidity associated with this disease. Lastly, the right main coronary artery was often more implicated than the left.

CONCLUSION

This review reiterates the significance of an accurate diagnosis and timely and effective interventions to improve prognosis. Finally, further large cohort studies and longer trials are needed to reach a definitive consensus on the best approach for coronary involvement in TAAD.

Protocol for Guo's aortIc Arch recoNstrucTion: a prospective, multicentre and single-arm study to evaluate the safety and efficacy of the WeFlow-Arch modular inner branch stent-graft system for aortic arch lesions (GIANT study)

INTRODUCTION

Endovascular repair of the entire aortic arch provides treatment opportunities for patients with aortic arch lesions who are intolerant to open surgery. However, the complex anatomical configuration, high-speed blood flow and long access from the femoral artery increase the difficulty of endovascular aortic arch repair. On the basis of our earlier studies, a new modular inner branch stent-graft system was developed specifically for lesions located in the aortic arch and part of the ascending aorta. This study aims to evaluate the safety and efficacy of the novel modular branch stent-graft system in patients with aortic arch lesions who are unsuitable for open aortic arch replacement.

METHODS AND ANALYSIS

This prospective, multicentre, single-arm, clinical trial will enrol 80 patients with aortic arch lesions requiring intervention, namely, true aortic arch aneurysms, pseudo-aortic arch aneurysms and penetrating ulcers involving the aortic arch. Clinical information and CT angiography (CTA) images will be collected and analysed to investigate the safety and efficacy of the novel modular branch stent-graft system. Patients will be followed up for 5 years. The primary outcome will be all-cause mortality and severe stroke within 12 months after the procedure. In addition, this trial will evaluate mid-term to long-term clinical and imaging outcomes through the annual clinical and CTA follow-up for 2-5 years postoperatively.

ETHICS AND DISSEMINATION

We have registered the study on a registry website (https://clinicaltrials.gov/ct2/home). The study findings will be disseminated through peer-reviewed journals, physician newsletters, conferences and the mass media.

TRIAL REGISTRATION NUMBER

NCT04765592.

“More or less”: management of type A aortic dissections in the endovascular era

The management of type A aortic dissection presents a major therapeutic challenge in modern surgical practice. Whilst the traditional dictum, to provide timely surgical intervention with the minimum treatment needed to repair the ascending aorta as well as the primary tear, may be a reasonable strategy in older patients, a tailored approach is desired for younger patients to manage the immediate life-threatening condition, as well as for the management of lifelong complications of the residual dissected aorta. Endovascular technology continues to advance, providing an adjunctive role to open cardiac repair presently to manage downstream aortic pathology, with the aim of striving towards a complete endovascular solution for type A aortic dissections.

Acute aortic syndromes: a review of what we know and future considerations

Acute aortic syndromes represent a spectrum of life-threatening aortic pathologies. Prompt diagnosis and proper management of these syndromes are important in reducing overall mortality and morbidity, which remains high. Acute aortic dissections represent most of these aortic wall pathologies, but intramural haematomas and penetrating atherosclerotic ulcers have been increasingly diagnosed. Type A dissections require prompt surgical treatment, with endovascular options on the horizon. Type B dissections can be complicated or uncomplicated, and treatment is determined based on this designation. Complicated Type B dissections require prompt repair with thoracic endovascular aortic repair (TEVAR) becoming the preferred method. Uncomplicated Type B dissections require medical management, but early TEVAR in the subacute setting is becoming more prominent. Proper surveillance for an uncomplicated Type B dissection is crucial in detecting aortic degeneration and need for intervention. Intramural haematomas and penetrating atherosclerotic ulcers are managed similarly to aortic dissections, but more research is needed to determine the proper management algorithms. Multi-disciplinary aortic programmes have been shown to improve patient outcomes and are necessary in optimizing long-term follow-up.

CT of Postoperative Repair of the Ascending Aorta and Aortic Arch

While many of the classic open surgical repairs are still used to repair the ascending aorta, management of the aortic arch has become more complex via implementation of newer open surgical and endovascular techniques. Furthermore, techniques are often combined in novel repairs or to allow extended anatomic coverage. As such, a framework that rests on understanding the expected postoperative appearance is necessary for the diagnostic radiologist to best interpret CT studies in these patients. After reviewing the imaging appearances of the common components used in proximal aortic repair, the authors present a structured approach that focuses on the key relevant questions that diagnostic radiologists should consider when interpreting CT studies in these patients. For repair of the ascending aorta, this includes determining whether the aortic valve has been repaired, whether the sinuses of Valsalva have been repaired, and how the coronary arteries were managed, when necessary. In repairs that involve the aortic arch, the relevant considerations relate to management of the arch vessels and the distal extent of the repair. In focusing on these questions, the diagnostic radiologist will be able to identify and describe the vast majority of repairs. Understanding these questions will also facilitate improved understanding of novel repairs, which often use these basic building blocks. Finally, complications-which typically involve infection, noninfectious repair breakdown, hemorrhage, problems with endografts, or disease of the remaining adjacent aorta-will be identifiable as deviations from the expected postoperative appearance. Online supplemental material is available for this article. ^©RSNA, 2021.

GUIDANCE ON AREA OF CREATED TEARS FOR AORTIC FENESTRATION TREATMENT BASED ON COMPUTATIONAL FLUID DYNAMICS

Aortic fenestration (AF) uses puncture and a dilation balloon to create a tear in the intimal flap, which can directly relieve ischemia syndrome and reduce hypertension in the false lumen. The selection of a dilation balloon as well as the area of the created tear applied in reality depend on clinical experience, so we aim to provide a quantitative guidance and reference for doctors to better plan the treatment of aortic fenestration. In this study, the area of the created tear was virtually enlarged to at least 10 different values for four cases including one ideal case, and a computational fluid dynamic approach was applied to simulate blood flows in the aorta. The area ratio (AR) between the created tear and entry tear was introduced to express the enlargement of the created tear. The quantitative hemodynamic results indicate that the AR should be controlled to be larger than 7.0, but not too big to obtain the best treatment for acute aortic dissection (AD) case. Additionally, we assessed that AR might also be a risk factor for the prediction of dissection propagation.

Anesthetic Considerations in Endovascular Repair of the Ascending Aorta

Since the first endovascular aortic repair in 1990, endovascular devices and the indications for their use have significantly grown. Considerable progress has been made in endovascular devices and techniques, such that endovascular repair is now considered first-line treatment for patients with descending aortic disease. However, for patients with ascending aortic disease, open surgical repair with cardiopulmonary bypass and hypothermic cardiac arrest was the only option until recently. Although the outcomes for open surgical repair of the ascending aorta have improved over the years, approximately 30% of patients with an emergent surgical indication, such as type A aortic dissection, are considered to be too high risk for open repair. For these patients, endovascular repair of the ascending aorta offers a life-saving procedure. The ascending aorta is regarded as the final frontier for endovascular therapy. Endovascular repair of it has posed a formidable challenge thus far, due to its unique anatomy, hemodynamic forces, and lack of an appropriate stent-graft designed specifically for the ascending aorta. Although currently there are no comprehensive data from randomized clinical trials, there are several case series and case reports that have shown favorable outcomes. Improvements in available devices soon will drive an exponential increase in the number of patients undergoing endovascular ascending aortic repair. In this review, the authors discuss multiple aspects of endovascular ascending aortic repair including the unique surgical and anesthetic considerations, the devices used, and the available outcomes data, and future directions are also explored.