Accepted Manuscript

Ascending Aorta Endovascular Repair of a symptomatic penetrating atherosclerotic

ulcer with a custom made endo-graft

Theodoros Kratimenos, Nikolaos G. Baikoussis, Dimitrios Tomais, Michalis Argiriou

PII: S0890-5096(17)30975-5
DOI: 10.1016/j.avsg.2017.08.027
Reference: AVSG 3563

To appear in: Annals of Vascular Surgery

Received Date: 17 June 2017

Revised Date: 31 July 2017
Accepted Date: 3 August 2017

Please cite this article as: Kratimenos T, Baikoussis NG, Tomais D, Argiriou M, Ascending Aorta
Endovascular Repair of a symptomatic penetrating atherosclerotic ulcer with a custom made endo-graft,
Annals of Vascular Surgery (2017), doi: 10.1016/j.avsg.2017.08.027.

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1 Ascending Aorta Endovascular Repair of a symptomatic penetrating atherosclerotic ulcer

2 with a custom made endo-graft

3 Theodoros Kratimenos1, Nikolaos G. Baikoussis2, Dimitrios Tomais1, Michalis Argiriou2

4 1. Interventional Radiology Unit, Radiology department, Evangelismos General Hospital of

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5 Athens, Greece.

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6 2. Cardiovascular and Thoracic surgery department, Evangelismos General Hospital of
7 Athens, Greece.

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9 Corresponding author:

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Dr Nikolaos G. Baikoussis MD, MSc, PhD
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11 45-47 Ipsilantou Street, 10676 Kolonaki Athens, Greece.
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12 Phone number: 00306974201838

13 E-mail: nikolaos.baikoussis@gmail.com
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23 Abstract

24 Background. Thoracic endovascular aortic repair (TEVAR) has become lately the procedure of
25 choice in the treatment of most pathologies of descending thoracic aorta. Aortic arch aneurysms
26 also came to be treated by TEVAR with various hybrid techniques or custom made

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27 scalloped/fenestrated stent-grafts. Zone 0; ascending TEVAR is more challenging than TEVAR
28 of the descending thoracic aorta or aortic arch because of the more complex pathology,

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29 hemodynamics, and anatomy. Ascending TEVAR can be a lifesaving treatment in selected high
30 surgical risk patients.

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31 Case Report. A male 71 years old with known history of respiratory insufficiency, coronary
32 artery disease (CAD) and low left ventricle ejection fraction (LVEF), presented to emergency

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33 department with acute thoracic pain. As the initial laboratory tests and the electrocardiogram
34 were negative for acute coronary syndrome, a computed tomography (CT) scan was performed
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35 that showed a 20 mm large and 17 mm depth penetrating atherosclerotic ulcer (PAU) in the
36 middle portion of ascending thoracic aorta. After medical therapy administration the thoracic
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37 pain was controlled and due to the high surgical risk of the patient, high incidence of aortic
38 rupture due to PAU and favorable anatomic conditions, was scheduled the implantation of a
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39 custom made (due to short ascending aorta) stent graft (Bolton, Relay Plus). A pacemaker was
40 implanted one week prior the operation in order to induce rapid ventricular pacing during the
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41 stent-graft deployment. During the operation the patient was under general anesthesia as it was
42 our first case treated in this way. The delivery of the graft was achieved through a right femoral
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43 artery open cut over an extra-stiff guide wire (lunderquist Cook) that was placed through an
44 angio-catheter into the left ventricle of the heart. The final positioning and deployment of the
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45 graft was achieved under rapid ventricular pacing and the final angiogram after the withdraw of
46 the graft delivery system showed exclusion from circulation of PAU, patency of coronary
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47 arteries and brachiocefalic trunk with competent aortic valve.

48 Conclusions. TEVAR of the ascending aorta is a safe and feasible technique indicated mainly
49 for unfit for open surgery patients.

50 Key words: endovascular surgery, stenting of the ascending aorta, penetrating atherosclerotic
51 ulcer, acute aortic syndrome, endo-graft, zone 0, landing zone, PAU, acute aortic dissection.
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52

53 Introduction.

54 Pathologies of the ascending thoracic aorta can be challenging to treat because of their
55 complexity and the considerable risk of a classical open surgical repair, especially in unfit

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56 patients with previous surgery in the aortic root, ascending aorta, or proximal aortic arch.
57 Endovascular surgery is a maturing technology that can facilitate treatment of complex aortic

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58 lesions but is used mainly for diseases of the descending thoracic aorta. Endografts designed to
59 treat ascending aortic disease are not commercially available yet. Because of anatomic

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60 considerations, the lack of specifically designed devices, and off label use, this technology is
61 rarely applied to the ascending aorta [1]. The whole pathology of the ascending aorta may be

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62 treated via in endovascular way especially in patients unfit for open surgical treatment. In the
63 international bibliography has been described patients treated via TEVAR for acute and chronic
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64 aortic dissection, pseudoaneurysm, chronic aneurysmatic dilatation, intramural haematoma
65 (IMH) and traumatic rupture of the ascending aorta [1,2,3,4]. As new technology and limited
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66 application of TEVAR in zone 0, many complications have been described in accepted range.
67 Endoleak, migration, stroke, myocardial infarction, in-hospital mortality, conversion to open
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68 surgery and the need for re-intervention (endovascular or open surgery) was described in the
69 bibliography [1,2,3,5,6]. We would like to present an interesting case with penetrating
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70 atherosclerotic ulcer (PAU) treated in endovascular way in our institution.

71 Case presentation
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72 A 71-year-old male patient was admitted with chest pain and dyspnea. As the electrocardiogram
was negative and an acute coronary syndrome was excluded, a full body computed tomography
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74 scan was performed with intravenous contrast media in order to assess the whole
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75 thoracoabdominal aorta. His history included coronary artery disease under medical therapy, low
76 left ventricle ejection fraction (LVEF 30%) and chronic obstructive pulmonary disease (COPD).
77 In the thorax CT scan a PAU of 20 mm large and 17 mm of depth was detected other than pleural
78 effusion in both haemithorax (figure 1, 2 and 3). In the abdominal CT scan a new-synchronal
79 diagnosed cancer of the pancreas to be treated surgically as soon as possible. As this patient
80 considered high surgical risk and unfit for open surgical treatment the endovascular repair was
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81 discussed. The lesion, PAU, was located in the middle portion of the ascending aorta with
82 excellent proximal and distal neck; the so-called favorable anatomy for endovascular
83 management [4]. Then, this patient required a less invasive treatment for fast recovery and the
84 minimal immunosuppression caused due to coexistence of the pancreatic tumor. The
85 extracorporeal circulation had to be avoided in order to minimize the tumor dissemination and

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86 the deleterious transfusions effects taken under considerations the less invasive-endovascular
87 way of treatment. As the commercially available endografts are 10 mm long or more, a custom

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88 made of 65 mm long and 38 x 38 of diameter graft of the Bolton Relay Plus (Bolton Medical -
89 Sunrise, FL 33325 USA) was ordered. Under general anaesthesia, and pace maker implantation

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90 through the femoral vein for rapid ventricular pacing in order to facilitate the graft deployment,
91 an angiography was performed. The delivery system was then passed through the right femoral

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92 artery till the left ventricle. Thenosecone of the delivery system had to be passed through the
93 aortic valve and into the left ventricle (LV) to position the endograft at the appropriate
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94 deployment location. The proximal markers of the graft had to be over the sino-tubular junction
95 and the distal, before the origin of the innominate artery to avoid branch occlusion (figure 4 and
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96 5). Routine aortography of the ascending aorta from the sinus of Valsalva was used to localize
97 the lesion, the orifice of the coronary arteries, the leaflets of the aortic valve and the branches of
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98 the aortic arch. Under controlled blood hypotension due to rapid ventricular pacing and careful
99 stent graft deployment the PAU was successfully excluded from the circulation, without
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100 endoleak while the aortic valve, the coronary ostia and the innominate artery remain intact
101 (figure 6). The patient had an uneventful postoperative with fast recovery and was programmed
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102 for therapeutic pancreatectomy due to cancer. In the first month CT scan follow-up, the patient
103 was asymptomatic in good clinical status without endoleak, migration or vessel occlusion (figure
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104 7).
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105 Discussion: Conventional treatment of ascending aortic aneurysm or dissection is open surgical
106 repair, but some patients are too high risk for this operation with extracorporeal circulation and
107 deep hypothermic circulatory arrest and may benefit from a less invasive alternative with
108 TEVAR [2]. Unfortunately, up to 25% of patients are denied surgical therapy because they are
109 deemed medically unfit to undergo open repair. The application of TEVAR has changed the
110 treatment paradigm for aortic disease involving the descending thoracic aorta and may be a
111 viable rescue option for patients with type A dissection and the rest of the ascending aorta
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112 pathology who are not eligible for open surgical repair. In a high percentage (30%) of patients
113 referred for endovascular repair of the ascending aorta was unsuitable due to absence of proximal
114 neck or other unfavorable anatomical characteristics was present [5]. In this case a high risk
115 surgery or the conservative treatment may be choosing. Trans-esophageal echocardiography
116 (TEEC) is used to better control the location of the lesion, the correct graft implantation and the

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117 function of the aortic valve at the end of the procedure. The use of rapid ventricular pacing was
118 mandatory in order to diminish cardiac output and blood pressure to facilitate accurate endo-graft

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119 deployment. However, when the nose cone of the deployment system contacted the LV wall,
120 ventricular tachycardia usually induced in every patient, resulting in significant hypotension. The

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121 endo-graft was deployed rapidly and, after the delivery system was withdrawn from the
122 ventricle, ventricular tachycardia or fibrillation resolved in most cases within 30 seconds. Some

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123 limitations of this procedure has been described like the presence of a mechanical aortic valve,
124 the patent grafts originating from the ascending aorta (of a previous aorto-coronary bypass). The
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125 access is usually the femoral arteries but the trans-apical approach, the axillary arteries, the
126 carotid arteries has been used [4,5]. In the bibliography every endo-graft fabricated for the
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127 descending thoracic aorta is implanted, off labeled, as well as, in the ascending aorta [3]. New
128 endovascular devices and endografts adopted for the ascending aorta, the use of the hybrid
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129 operating rooms and advanced image-guided procedures are continually evolving [4]. Large
130 series, meta-analysis and long-term survival trials are mandatories to standardized TEVAR in the
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131 ascending aorta [5].

132 Conclusions: TEVAR of the ascending aorta is a new way of treatment of its whole pathology.
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133 It is a safe and feasible technique indicated mainly for high surgical risk and unfit for open
134 surgery patients.
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136

137 References.

138 1. Preventza O, Henry MJ, Cheong BY, Coselli JS. Endovascular repair of the ascending
139 aorta: when and how to implement the current technology. Ann Thorac Surg. 2014
140 May;97(5):1555-60.
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141 2. Roselli EE, Idrees J, Greenberg RK, Johnston DR, Lytle BW. Endovascular stent grafting
142 for ascending aorta repair in high-risk patients. J Thorac Cardiovasc Surg. 2015
143 Jan;149(1):144-51.

144 3. Tsilimparis N, Debus ES, Oderich GS, Haulon S, Terp KA, Roeder B, Detter C, Klbel

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145 T. International experience with endovascular therapy of the ascending aorta with a
146 dedicated endograft. J Vasc Surg. 2016 Jun;63(6):1476-82.

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147 4. Shah A, Khoynezhad A. Thoracic endovascular repair for acute type A aortic dissection:
148 operative technique. Ann Cardiothorac Surg. 2016 Jul;5(4):389-96.

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149 5. Li Z, Lu Q, Feng R, Zhou J, Zhao Z, Bao J, Feng X, Feng J, Pei Y, Song C, Jing Z.
150 Outcomes of Endovascular Repair of Ascending Aortic Dissection in Patients Unsuitable

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151 for Direct Surgical Repair. J Am Coll Cardiol. 2016 Nov 1;68(18):1944-1954.
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152 6. Moon MC, Greenberg RK, Morales JP, Martin Z, Lu Q, Dowdall JF, Hernandez AV.
153 Computed tomography-based anatomic characterization of proximal aortic dissection
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154 with consideration for endovascular candidacy. J Vasc Surg. 2011 Apr;53(4):942-9.

155 Figure legends.

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156 Figure 1. The preoperative CT scan with the PAU (arrow).

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157 Figure 2. A reconstructed image with the PAU in the middle portion of the ascending aorta
158 (arrow).
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159 Figure 3. Colored reconstruction of the preoperative CT scan.

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160 Figure 4. Intraoperative angiography. The delivery system has been passed through the aortic
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161 valve into the left venticle. The markers of the proximal end of the graft are in the lavel of the
162 sino-tubular junction. PAU is well seen. The stent graft has to be expanded in the ascending
163 aorta in order to cover the PAU.

164 Figure 5. Intraoperative image. Stent graft deployed. The endotracheal tube and the pacing wires
165 are also seen.
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166 Figure 6. Final angiography with good results; no endoleak, no coronary ostia and innominate
167 artery occlusion, with competent aortic valve and PAU exclusion from the circulation.

168 Figure 7. First-month follow-up reconstructed image; Excellent results.

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