Eastern Cardiothoracic Surgical Society

Thoracic Endovascular Stent Graft Repair for the Treatment of Ascending Aortic Pathologies in High Open Surgical Risk Patients
Jean Paul Gottret, Prashanth Vallabhajosyula, Patrick Moeller, William Moser, Karianna Milewski, Nimesh Desai, Joseph Bavaria, Wilson Y. Szeto,  University of Pennsylvania, Philadelphia, PA

OBJECTIVE: Treatment of ascending aortopathies in patients with prohibitive comorbid burden poses a major surgical challenge. We report the application of thoracic endovascular aortic repair(TEVAR)technology as alternative treatment modality in this high surgical risk cohort.

METHODS: From 2004 to 2012, 6 patients(age range 16 to 92 years;male n=3)presenting with emergent/ urgent ascending aortic pathology deemed prohibitively high open surgical risk underwent TEVAR in the hybrid operating room. Indications included aortic dissection(n=2)and pseudoaneurysm formation after previous ascending aortic repair.

RESULTS: Access was obtained via transfemoral(n=1), left common carotid(n=1), and transapical(n=4)approaches. Cook-TX2 stent graft was utilized in 5 cases(dissection n=2,pseudoaneurysm n=3). Stent coverage extended from the sinotubular junction to innominate artery origin. In one patient, aortic pseudoaneurysm neck was occluded with an Amplatzer device. Completion angiography confirmed successful exclusion of all aortic lesions. Complication rates were stroke17%(n=1)and respiratory failure17%(n=1), in-hospital and 30-day mortality, renal failure, and coronary complication rates were all zero. Mean hospital stay was 9 days(range 5-15 days). Discharge CT imaging showed one type I endoleak(rate 17%)and no stent migration. Mean follow-up was 20 months(range 2-42 months).One patient developed type I endoleak at 7 months, and two patients died at 3 and 27 months from non-aortic related causes.

CONCLUSIONS: Current TEVAR platform designed for descending thoracic aorta can be safely translated for the treatment of ascending aortopathies in patients with prohibitive open surgical risk.Tailoring stent graft and delivery sheath technology to adapt to ascending aortic anatomy will be a necessity before this methodology can be more safely and widely applied.