Endovascular repair of ascending aortic pathologies in patients unfit for open surgery: Case series and literature review

The number of vascular centres performing endovascular repair of ascending aortic diseases is constantly increasing. Accordingly to the guidelines, open surgical repair remains the gold standard for these pathologies but approximately one quarter of patients are deemed unfit for open surgery risk.In this study we described 3 cases of aTEVAR performed at our center. All the patients were deemed unfit for open surgery by the aortic team. Two patients had an ascending aortic pseudoaneurysm, whereas the latter had a focal type A aortic dissection. In two cases we used 2 abdominal aortic cuff deployed from zone 0B to zone 0C, with no need for any supra-aortic trunk debranching. In one case we performed a "reverse" extra-thoracic debranching and we deployed a thoracic endograft from zone 0B to zone 2. Complications included one minor stroke and one inguinal hematoma. In one patients with infected psudoaneurysm we performed aTEVAR as a bridge strategy for open repair. This patient developed a type Ia endoleak, but clinical stabilisation and infection control were obtain and he was able to undergo heart surgery successfully. He underwent a second reintervention due to superior mesenteric embolic occlusion. At 2 year follow-up all three patients were alive.Our preliminary experience demonstrates the technical feasibility and clinical appropriateness of ascending TEVAR using standard, commercially-available endografts. However, no consensus exists on some critical aspects, such as the development of a standardized technique or the efficacy of the currntly available devices. The improvements in graft design and the adoption of the "aortic team" approach could help in the near future to standardize the procedure, establish appropriate indications, and ensure good clinical outcomes.