From zone 1 to zone 3: Feasibility and safety of complex endovascular aortic repairs in type A aortic dissection.

OBJECTIVE

More than 30% of patients presenting with acute type A aortic dissection are considered high risk or inoperable. This study aims to investigate the early and midterm outcomes of complex endovascular aortic repair of aortic root, ascending aorta, and aortic arch among patients with acute type A aortic dissection.

METHODS

From January 2018 to January 2023, 29 patients who were considered high risk for open operation underwent endovascular aortic repair. Patients were considered high risk because of frailty (n = 14), severe malperfusion (n = 5), chronic obstructive pulmonary disease and on home oxygen (n = 4), frozen chest (n = 3), metastatic cancer (n = 3), ejection fraction <20% (n = 4), and cirrhosis (n = 2). For an isolated tear in the ascending aorta (zone 0), ascending stent graft placement was performed using commercially available aortic stent grafts. For patients with a tear in the aortic root, Endo-Bentall was performed using a physician-modified modular device composed of a self-expanding transcatheter aortic valve incorporated inside an aortic stent graft. For patients with a tear in the ascending aorta as well as the aortic arch (zone 0, zone 1, 2), ascending stent graft placement and endovascular arch repair was performed. Follow-up electrocardiogram-gated computed tomography was performed to evaluate aortic remodeling.

RESULTS

The mean age for this cohort was 76.3 ± 11.1 years. Endovascular repairs included isolated ascending stent placement in 65.5% (19/29), endo-Bentall in 6.9% (2/29), endo-Bentall plus endo arch in 6.9% (2/29), and ascending thoracic endovascular repair + endo arch in 20.7% (6/29). The operative mortality was 10.3% (3/29). Stroke rate was 10.3% (3/29). During the follow-up time of a median of 6.25 months (range, 0.85-64.6 months), an endoleak was observed in 42.3% (11/26) patients (80% among patients with a tear <2 cm of sinotubular junction). Seven patients had a type 1a endoleak, whereas 4 patients had a type 1b endoleak on follow-up computed tomography angiography. Three patients required reintervention. The Kaplan-Meier 5-year probability of survival for the entire cohort post-intervention was 35%.

CONCLUSIONS

Early outcomes of complex endovascular repair of ascending aortic dissection are promising with acceptable mortality and stroke rate. However, the rate of endoleak after isolated ascending thoracic endovascular repair with a tear within 2 cm of the aortic root is high with poor long-term survival.