Endovascular repair of aortic arch lesions in high-risk patients or after previous aortic surgery: Midterm results

Introduction: At present, there are not risk scoring tools to predict in-hospital mortality for total aortic arch replacement (TAR), Hypothesis: To assess if Logistic Euroscore (LogES) is a useful tool for risk assessment in aortic arch surgery and which other operative factors may help to better identify high-risk patients. Methods: All patients who underwent open arch procedure between 1998 and 2013 were identified from our prospectively collected database which include 93 preoperative variables. Results: Three-hundred-fifty-seven open arch procedures were identified. Two-hundred-forty-two patients underwent TAR, 199 with conventional technique and 43 with frozen elephant trunk (FET) technique. Patients with higher LogES had higher in-hospital mortality (see table 1). Patient with a LogEs <20, 20-60 and >60 were classified as low-, high- or very high-risk, respectively. Complexity of surgery, defined as need for aortic root replacement (ARR) and/or mitral valve repair/replacement (MVR), increased significantly the risk of operation (27% vs. 4.2%, p:0.004) only in conventional TAR in high-risk patients. Low-risk patients were associated with low mortality regardless the extent of surgery whilst very high risk-patients had a high-risk of death even with simple operations. Mortality risk in FET was not increased by need for ARR/MVR. Rate of permanent neurological deficit remained low in all category of patients. Spinal cord injury (SCI) did not occur in any conventional TAR. Conclusions: Open surgery should remain the treatment of choice for patients with low/moderate LogES and high LogES without need for ARR/MVR. Patient with very-high LogES who do not need ARR/MVR should be consider for endovascular repair. Patient with high and very-high LogES and need for ARR/MVR cannot undergo endovascular treatment and remain a significant challenge. FET remains a procedure with an increase risk of death and SCI.

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Faculty Opinions recommendation of Outcomes of thoracic endovascular aortic repair using aortic arch chimney stents in high-risk patients.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.727328539.793529166 ◽

2017 ◽

Author(s):

John Augoustides

Keyword(s):

High Risk ◽

Aortic Arch ◽

Thoracic Endovascular Aortic Repair ◽

Endovascular Aortic Repair ◽

High Risk Patients ◽

Aortic Repair ◽

Risk Patients

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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

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytz043 ◽

2019 ◽

Vol 3 (2) ◽

Cited By ~ 1

Author(s):

Josephine Chenesseau ◽

Pierre-Antoine Barral ◽

Philippe Piquet ◽

Marine Gaudry

Keyword(s):

Cardiac Surgery ◽

High Risk ◽

Endovascular Treatment ◽

Endovascular Repair ◽

Innominate Artery ◽

Ascending Aorta ◽

Stent Grafts ◽

Penetrating Atherosclerotic Ulcer ◽

High Risk Patients ◽

Risk Patients

Abstract Background An endovascular approach to the management of a ruptured plaque in the ascending aorta may be an alternative to open surgery in high-risk patients. This option may become inevitable due to the number of elderly patients unfit for open cardiac surgery. There are very few stent grafts able to fit the ascending aorta and in emergency cases, most medical teams have been limited to current thoracic aortic endografts, the shortest of which measure 10 cm. Case summary We report a case of an endovascular repair of a ruptured penetrating atherosclerotic ulcer of the ascending aorta. The patient was considered for open cardiac surgery but was evaluated at a high mortality risk based on his age, his medical history, and significant calcifications on his aorta. Our vascular surgical team decided then to perform an endovascular repair with extending the length of the aortic coverage by debranching the innominate artery. Discussion Endovascular treatment of an acute ruptured aorta is feasible in high-risk patients with thoracic endovascular stent grafts and coverage of the innominate artery. Endovascular treatment of the ascending aorta is at its infancy and in need of further research. New stent grafts designed for the ascending aorta are in progress and should increase the numbers of interventions in the years to come.

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