Is an endovascular treatment for patients with a typa A aortic dissection anatomically feasible?

Background Surgery is the only established treatment for patients with acute Type A aortic dissection, yet postoperative mortality remains high and has shown little improvement in recent years. Purpose This study aimed to provide anatomical insights for a potential stent-graft treatment to close the primary entry tear in a dissected ascending aorta. Methods Between 2013 and 2023, 416 patients were surgically treated for an acute Type A aortic dissection in a single institution. In 87 patients, preoperative high resolution computed tomography scans were available for detailed aortic measurements. In 36 patients, the primary entry tear was located in the tubular ascending aorta and compose the study population. Results Simulating a transapical approach, a median distance of 43 [first quartile: 36; third quartile: 55] mm and 89 [85; 97] mm was measured from skin to apex and from apex to the aortic annuls respectively. The angle from ventricle to annulus was 47 [42; 53] degrees. The distance from the sinotubular junction (STJ) to the primary entry tear was 25 [12; 44] mm but reached 49 [37; 68] mm measured from the aortic annulus. The distance from the distal end of the primary entry tear to the brachiocephalic trunk (BCT) was 30 [13; 47] mm. Median diameter of the aortic root, the the true lumen at the STJ and the true lumen proximal to the BCT were 24 [21; 27] mm, 31 [27; 34] mm, and 31 [27; 36] mm respectively. The ratio of the diameter STJ to BCT was 1.0 [0.9; 1.1]. The height of the aortic root was 25 [23; 28] mm. Conclusions With a 20 mm stent-graft landing zone, most patients would not qualify for an isolated stent-graft treatment to close a primary entry tear in the tubular ascending aorta due to the short distance between the STJ and the entry tear. However, anchoring a stent-graft to a transcatheter aortic valve at the aortic annulus would eliminate the need for a dedicated landing zone. In this approach, adequate sealing of the stent-graft appears feasible both proximally and distally to the primary entry tear in most patients. Additionally, the need for stent-graft oversizing could be significantly reduced, and a straight stent-graft with equal proximal and distal diameters would likely suffice for the majority of patients.Aortic Measurments