The Endo-Bentall Procedure in the Treatment of Ascending Aorta Pathologies: A Scoping Review

OBJECTIVE: The ascending aorta remains a challenging area for endovascular repair, with limited anatomical suitability of current stent grafts due to proximal landing zone constraints. This scoping review summarised, existing experiences with the Endo-Bentall procedure, evaluated its use across pathologies, identified obstacles, and proposed future advances. DATA SOURCES: PubMed, Cochrane, and Embase were systematically searched (English language, up to 30 November 2024) for studies evaluating the Endo-Bentall procedure in treating ascending aortic pathologies. REVIEW METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol extension for scoping reviews was followed, and data were reported as descriptive narratives or tables. RESULTS: Twenty studies were included, comprising case reports, anatomical feasibility analyses, reviews, expert opinions, and technical notes. Proof of concept studies in ex vivo (n = 30) and in vivo (n = 20) models achieved 95 - 100% technical success rates, with sustained coronary patency. Five cases were reported; indications included aortic dissection (n = 2), aneurysm (n = 1), and post-surgical complications (n = 2). Balloon expandable transcatheter aortic valve implantation (TAVI) platforms were used in three cases (one used single stage and two used two stage procedures), while self expanding platforms were used in two cases (single stage). Technical success was achieved in all cases. Early follow up showed favourable outcomes in two of three balloon expandable cases and two of two self expanding cases. One patient died at 5 months (non-aortic cause). Anatomical feasibility studies for aortic dissection (n = 547) and aortic aneurysm (n = 80) demonstrated a median suitability rate of 68% (31 - 80%) for various device designs. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology suggested a very low certainty regarding clinical outcomes. CONCLUSION: The Endo-Bentall procedure is an emerging endovascular approach for ascending aortic pathologies, particularly for patients at high surgical risk. Early experience suggests feasibility. However, the current literature is significantly limited by publication bias and methodological heterogeneity. Further research is required, with systematic evaluation to optimise device development, surgical technique, bailout strategies, and long term outcomes.