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Two cases of PAU of the distal aortic arch (A,B) and of the descending thoracic aorta (C,D,E,F). Axial images (A1-A3) show the enlargement evolution of a "blister-like" lesion over a 2-year period. Volume rendering 3D reconstructions show, preoperatively (B1), the location and the typical calcifications surrounding focally only the aorta affected by the PAU. Postoperatively (B2) the result of TEVAR after 24 months follow-up with the complete exclusion of the lesion, and the good apposition of the SG at the inner curve in such a Romanesque aortic arch. Preoperative CTA of a contained rupture (C) of a descending PAU with the typical calcifications of the entire aorta (D). Volume rendering 3D reconstructions of the same case: preoperative (E) and postoperative (F) after 12 months of follow-up. PAU, penetrating aortic ulcer; TEVAR, thoracic endovascular aortic repair.
Source publication
Background:
To analyze our experience and to describe access and arch-related challenges when performing thoracic endovascular aortic repair (TEVAR) for penetrating aortic ulcers (PAUs).
Methods:
This is a single-center, observational, cohort study. Between October 2003 and February 2019, 48 patients with PAU were identified; 37 (77.1%) treated...
Contexts in source publication
Context 1
... Asymptomatic lesion with diameter ≥30 mm and/or depth ≥10 mm ( Figure 1A,B); Asymptomatic progressively enlarging "blister-like" lesion ( Figure 2); Saccular pseudoaneurysm ≥50 mm or aortic lesion evolution into classic aortic dissection with detection of perfused true and false lumens; ...
Context 2
... Symptomatic lesion (typical chest/back pain) in the presence of signs of impending rupture (crescent sign, pleural effusion) and/or persisting symptoms despite best medical treatment; "Shaggy aorta" with visceral/peripheral embolization syndrome; Free (hemothorax) or contained (periaortic hematoma) rupture ( Figure 2C,D,E). Patients diagnosed and treated for PAU located in the ascending aorta were not included in this analysis. ...
Context 3
... Asymptomatic lesion with diameter ≥30 mm and/or depth ≥10 mm ( Figure 1A,B); Asymptomatic progressively enlarging "blister-like" lesion ( Figure 2); Saccular pseudoaneurysm ≥50 mm or aortic lesion evolution into classic aortic dissection with detection of perfused true and false lumens; ...
Context 4
... Symptomatic lesion (typical chest/back pain) in the presence of signs of impending rupture (crescent sign, pleural effusion) and/or persisting symptoms despite best medical treatment; "Shaggy aorta" with visceral/peripheral embolization syndrome; Free (hemothorax) or contained (periaortic hematoma) rupture ( Figure 2C,D,E). Patients diagnosed and treated for PAU located in the ascending aorta were not included in this analysis. ...
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Methods
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Citations
... 1 It has been postulated that this leads to a higher complication rate during endovascular repair, namely, stroke. 2 Despite this, thoracic endovascular aortic repair (TEVAR) has shown safe and effective outcome for PAUs in the descending aorta, and also in patient populations with significant vascular comorbidity and older age. [3][4][5][6][7] As up to 18% of the PAUs are located in zone 0 to 2, 8 they are not amenable to conventional TEVAR. ...
Purpose
In penetrating aortic ulcers (PAUs), limited data support tubular thoracic endovascular aortic repair (TEVAR) as a viable treatment option. For treatment of more proximal PAUs, hybrid approaches and—more recently—scalloped TEVAR (scTEVAR) have been advocated. Outcomes of scTEVAR specifically for PAUs have not yet been reported. This study reports long-term outcomes for tubular and scTEVAR in PAUs and compares the safety profile in both cohorts regarding the significantly more proximal landing zone (LZ) for scTEVAR.
Materials and Methods
This single-center retrospective cohort study includes all nonacute patients treated for complicated PAU with scTEVAR and tubular TEVAR. Patient and PAU characteristics as well as procedural success, complication and reintervention rates, and all-cause and aortic mortality were analyzed.
Results
Of 212 TEVAR procedures reviewed, 21 patients with tubular TEVAR and 19 patients with scTEVAR were included. Patient and PAU characteristics were similar, and LZ was significantly more proximal in the scTEVAR cohort (p=0.0001), with similar number and types of supra-aortic revascularization procedures. Clinical success was reached in all 40 patients (100%), and reintervention rate was 2/21 (9.5%) and 1/19 (5.3%), respectively. Over the mean follow-up of 63 (TEVAR) and 53 (scTEVAR) months, clinical success was stable in all patients with one (abdominal) aortic-related mortality in the scTEVAR cohort.
Conclusion
Treatment of complicated PAUs with TEVAR as well as scTEVAR provides excellent and similar clinical success, stability of clinical success, and aortic survival with acceptable complication and reintervention rates. Scalloped TEVAR safely lengthens the proximal sealing zone to address more proximal pathologies.
Clinical Impact
Treatment of asymptomatic complicated penetrating aortic ulcers (PAUs) with thoracic endovascular aortic repair (TEVAR) provides excellent clinical success and acceptable complication and reintervention rates. More patients become amenable to endovascular treatment by including scalloped TEVAR (scTEVAR) as a means to safely lengthen the proximal sealing zone to address more proximal pathologies.
... Third, these patients often had challenging femoral or iliac access and a subsequent high risk of technical (inability to advance the endograft or iliac rupture) and clinical failures. [17][18][19] In our series, 29% of the patients had bilateral severe femoral or iliac access, and in 16% of cases the external iliac artery diameter was less than 7 mm. These challenging anatomic features justify also the high rate of femoral surgical cut-down that represented the 74% of the overall access in our series. ...
Introduction
Penetrating Aortic Ulcer (PAU) is determined by atherosclerotic degeneration of the tunica media with disruption of the intima. Usually it is detected in the thoracic aorta, with only few series describing its abdominal location. Aim of the study was to report early and late outcomes of the endovascular repair of complicated infrarenal PAU (a-PAU) by aorto-bi-iliac endograft and embolization.
Methods
Data of all complicated a-PAU submitted to endovascular repair by aorto-bi-iliac endograft (Cook-Zenith Alpha) between 2016 and 2021(February) were analyzed. The a-PAU coil embolization was performed to reduce the risk of persistent type II endoleak whenever possible. Complicated a-PAU were defined according with the presence of symptoms, aortic rupture or saccular/pseudo-aneurysm. Technical success, 30-day morbidity/mortality and reinterventions were assessed as early outcomes. Survival, endoleaks and freedom from re-interventions were evaluated during follow-up.
Results
Out of 1153 endovascular aortic procedures, 45(4%) cases of complicated a-PAU were identified. Fourteen (31%) cases were managed in urgent setting (symptoms:10 -22%; shock:4 - 9%). The median diameter of a-PAU was 49(IQR:14) mm. Thirteen (29%) patients had severe femoral/iliac access [(angle >90°, circumferential calcification (>50%), hemodynamic iliac stenosis/obstruction, external iliac artery diameter <7mm, previous femoral surgical graft]. The a-PAU embolization was performed in 30(67%) cases. Technical success was achieved in all patients. Postoperative cardiac, pulmonary and renal morbidity occurred in 1(2%), 2(4%) and 8(18%) patients, respectively. Two (4%) patients required reintervention within 30 days for access related complications. The 30-day mortality was 2%. At a median follow-up of 24(IQR:18) months, no type I-III endoleaks, iliac leg occlusion or graft infection occurred and no patient required late reinterventions; 36-month survival was 72%. No a-PAU enlarged or ruptured during follow-up.
Conclusion
Endovascular repair of complicated a-PAU by a low-profile aorto-bi-iliac endograft and embolization is safe and effective. Excellent technical results are reported even in challenging anatomical features. Mid-term clinical results are satisfactory in terms of aortic related complications/mortality, freedom from reinterventions and survival.
... PAUs of the arch have been considered adequate anatomic targets for thoracic endovascular aortic repair (TEVAR), and thoracic PAUs have been defined as an ideal surgical indication for TEVAR [9,15]. However, PAUs developed in the arch are the most challenging to treat endovascularly, with a high mortality rate and arch and access vessel complications, due to the variability of the anatomy of the arch and its branches [16]. Kleisli and et al. [17] reported closure of a PAU of the descending aorta with an Amplatzer Occluder via percutaneous femoral access in 2009, the 12-month follow-up was also satisfactory. ...
Penetrating aortic ulcer (PAU) is one of the three subtypes of acute aortic syndrome. PAUs occur at any point throughout the aorta, most commonly in the descending thoracic aorta and less frequently in the aortic arch. Open surgical repair and total/hybrid endovascular repair are currently available to treat aortic arch PAUs. Herein, we present a patient with aortic arch PAU who underwent transthoracic minimally invasive closure, which is a novel method for the treatment of PAU. We describe a 52-year old Asian man who presented with sudden chest and back pain for 8 h. Computed tomography angiography showed that the PAU occurred in the aortic arch and had a diameter of 16 mm and a depth of 6 mm. The opening was successfully closed via transthoracic minimally invasive closure with an atrial septal defect occluder.
... The main difference here is that PAU is an obliterative aortic disease that makes these patients prone to multisite arterial disease such as coronary artery disease, carotid artery disease or peripheral arterial disease. Consequently, procedural risk, in particular for access vessel challenges, and most importantly for stroke, is higher [10]. It remains of utmost importance to anticipate risk during screening and to link findings of preoperative imaging to the potential complications caused by wire manipulation early and to rethink the treatment strategy. ...
Objectives:
Our goal was to evaluate results of endovascular aortic arch repair using the Relay Branch system.
Methods:
Forty-three patients with thoracic aortic pathology involving the aortic arch have been treated with the Relay Branch system (Terumo Aortic, Sunrise, FL, USA) in 10 centres. We assessed in-hospital mortality, neurological injury, treatment success according to current reporting standards and the need for secondary interventions. In addition, outcome was analysed according to the underlying pathology: non-dissective disease versus residual aortic dissection (RAD) (defined as remaining dissection after previous type A repair, chronic type B aortic dissections).
Results:
In-hospital mortality was 9% (0% in patients with RAD). Disabling stroke occurred in 7% (0% in patients with RAD); non-disabling stroke occurred in 19% (7% in patients with RAD). Early type IA and B endoleak formation occurred in 4%. Median follow-up was 16 ± 18 months. During the follow-up period, 23% of the patients died. Aortic-related deaths were low (3% in patients with RAD).
Conclusions:
The results of endovascular aortic arch repair using the Relay Branch system in a selected patient population with regard to technical success are good. In-hospital mortality is acceptable, the number of disabling strokes is low and technical success is high. Non-disabling stroke is a major concern, and every effort has to be taken to reduce this to a minimum. The best outcome is seen in patients with underlying RAD. Finally, more data are needed.
... In our view, aortic rupture could have occurred due to the fol- Complications related to the femoral artery access sites are also common. 25 The femoral arteries are cuff down to deploy the stent graft in most of the patients in our center. During the operation, it was found that the reversal of calcified intimal slice interrupted the blood flow distal to the femoral artery, resulting in thrombus formation. ...
Background
This study aimed to evaluate the clinical outcomes of one‐staged hybrid procedure for aortic lesions involving the distal aortic arch.
Methods
We retrospectively studied 99 consecutive patients who underwent the hybrid procedure (thoracic endovascular aortic repair combined with supra‐arch branch vessel bypass) in our center between April 2009 and January 2020 for lesions involving the distal aortic arch.
Results
Median age was 64.0 (57.0–69.0) years, and 83 (83.8%) patients were male. There were five deaths in the perioperative period (three due to cerebral infarction and two due to intimal rupture). During the median follow‐up of 41.0 months, 20 patients died, three had endoleak, one had a newly formed intimal tear, and two had femoral artery pseudoaneurysm. The 5‐ and 10‐year survival rates of the total population were 72.2% and 48.8%, respectively. Additionally, there was no difference in the 5‐year survival rate among the four groups according to different pathologies (Type B aortic dissection, aortic ulcer, aortic aneurysm, aortic pseudoaneurysm: 74.7%, 78.2%, 61.1%, and 75.5%, respectively, p = .58). Furthermore, there was no difference in the 5‐ and 10‐year survival rates between the two groups according to the different bypass methods (right axillary artery [RAA]‐left axillary artery [LAA] vs. RAA‐LAA‐left common carotid artery: 74.1% vs. 68.9%, p = .38).
Conclusions
Although one‐staged hybrid procedure has fewer complications in high‐risk patients with lesions involving the distal aortic arch, the long‐term survival rate is not optimistic.
... Thoracic endovascular aortic repair (TEVAR) has become the treatment of choice for patients with thoracic penetrating aortic ulcers (PAUs) beyond conservative management [1,2]. Nevertheless, TEVAR may not always be an option due to the lack of an adequate proximal landing zone and increased risk for retrograde type A aortic dissection, particularly in patients presenting additional aortic pathologies in more proximal aortic segments or because of intraluminal thrombus formations ( Fig. 1A-C) [2][3][4]. Moreover, the underlying obliterative disease in patients with PAUs may complicate or preclude an endovascular approach, whereas underlying cardiac pathologies may also require concomitant open cardiac surgery. ...
... In fact, a recent review analysing TEVAR outcomes in patients with thoracic PAUs revealed a combined mortality of 4.8% (15 of 310) and combined incidence of stroke of 2.4% (7 of 287) [3]. Nevertheless, the risk for retrograde type A aortic dissection, distal thromboembolism, endoleak formation and access difficulties remain problematic factors [3,4]. ...
OBJECTIVES
Our goal was to evaluate the use of the frozen elephant trunk (FET) technique for the treatment of penetrating aortic ulcers involving the aortic arch.
METHODS
Between January 2008 and January 2020, a total of 34 patients had the FET technique at 3 aortic centres. The indication for the FET technique was unsuitability for thoracic endovascular aortic repair due to the lack of a sufficient proximal landing zone even after supra-aortic rerouting (subclavian transposition, double transposition), ectasia of the ascending aorta/aortic arch (>40 mm) and/or a shaggy proximal thoracic aorta.
RESULTS
Additional cardiac procedures were performed in 14 patients (41%), and the beating heart technique was used in 7 patients (21%). Perioperative mortality was 18% (n = 6); 3 of these patients had a major stroke (9%). No case of spinal cord ischaemia was observed, and 2 patients (6%) developed a non-disabling stroke. After a median follow-up of 7 (first quartile: 1; third quartile 29) months, 2 patients (6%) died (1 of malignant disease and 1 of an unclear cause); 10 additional aortic interventions in all aortic segments (29%; endovascular: n = 8 [24%] and conventional surgical: n = 2 [6%]) were performed in 8 patients.
CONCLUSIONS
The FET technique is a good treatment option for patients with penetrating aortic ulcers involving the aortic arch unsuitable for thoracic endovascular aortic repair. However, the high obliterative atherosclerotic load in these patients is accompanied by an un-neglectable risk of perioperative neurological injury. Concomitant cardiac surgical procedures are frequently needed. Patients commonly require secondary aortic procedures in all aortic segments, emphasizing the need for thorough primary conceptual planning and stringent follow-up.
Objective
This review aims to comprehensively summarize access challenges in thoracic endovascular aortic repair (TEVAR) by describing vascular access routes, associated risks, outcomes, and complications.
Methods
A literature search was conducted utilizing the PubMed (Medline), Scopus, and Web of Science databases. Qualitative and quantitative data from selected studies are extracted and discussed according to available standards for narrative reviews.
Results
In total, there were 109 eligible studies based on predefined inclusion- and exclusion criteria. There were 39 original articles or reviews and 57 case-series or case-reports. This article summarizes the evidence from these studies and discusses traditional retrograde access routes and techniques for TEVAR via a femoral or iliac route, with or without the use of conduits. Next, alternative antegrade access routes and techniques via a brachial, axillary, carotid, ascending aorta, transapical, transcaval, or another route are discussed. Vascular access complications are presented with specific attention to the importance of gender and alternative, antegrade access routes.
Conclusion
Multiple access routes and techniques are currently available to overcome access challenges associated with TEVAR, based on low grade evidence from heterogeneous studies. Future research that compares different access routes and techniques might help in the development of a tailored access protocol for specific patients with challenging TEVAR access.
Introduction
The natural history of penetrating aortic ulcers (PAU) and intramural hematomas (IMH) of the aorta is not well described. While repair is warranted for rupture, unremitting chest pain or growth, there is no established threshold for treating incidental findings. Thoracic endovascular aortic repair (TEVAR) offers an attractive approach in treating these pathologies, however, peri-procedural and post-operative outcomes are not well defined.
Methods
Patients 18 or older identified in the VQI database who underwent TEVAR for PAU and/or IMH between 1/2011-2/2020 were included. We identified 1042 patients, of whom 809 had available follow-up data. Patient demographics and comorbidities were analyzed to identify risk factors for major adverse events (MAE), as well as postoperative and late mortality.
Results
The cohort was 54.8% female and 69.9% former smokers with a mean age of 71.1 years. Comorbidities were prevalent with 57.8% classified ASA IV; 89.8% had hypertension, 28.3% chronic obstructive pulmonary disease (COPD), 17.9% coronary artery disease, and 12.2% congestive heart failure (CHF). Patients were predominately symptomatic (74%) and 44.5% underwent non-elective repair. MAE incidence was 17%. Independent predictors of MAE were history of CAD, non-Caucasian race, emergent procedural indication, ruptured presentation, and deployment of two or more endografts. In-hospital mortality was 4.3%. Seventy-three percent of index hospitalization mortalities were treatment-related. Of 809 patients with follow-up (mean 25.1 months±19 months), all-cause mortality was 10.6%. Predictors of late mortality in follow-up included age greater than 70 years, ruptured presentation, and history of COPD and ESRD. Subset analysis comparing symptomatic (74%) vs. asymptomatic (26%) patients demonstrated the former were frequently female (58.2% vs. 45.3%, p<.001) with a higher incidence of MAE (20.6% vs. 6.9%, p<.001), notably higher in-hospital reintervention rates (5.9% vs. 1.5%, p=.002) and mortality (5.6% vs. 0.7%, log-rank p=.015), and prolonged length of stay (6.9 vs. 3.7 days, p<.0001) despite similar procedural risks. In follow-up, late mortality was higher in the symptomatic cohort (12.2% vs. 6.5%, log-rank p=.025), with all treatment-related mortalities limited to the symptomatic group.
Conclusions
We demonstrate significantly higher morbidity and mortality in symptomatic patients undergoing repair compared to asymptomatic patients, despite similar baseline characteristics. Asymptomatic patients treated with TEVAR had no treatment-related mortality in follow-up, with overall prognosis largely dependent on pre-existing comorbidities. These findings, in conjunction with growing evidence highlighting the risk of disease progression and attendant morbidity associated with these aortic entities, suggest a need for natural history studies and definitive guidelines on the elective repair of IMH and PAU.
Objective
To evaluate the technical success and short-term outcome of patients with penetrating aortic ulcers (PAUs) and saccular aneurysms (SAs) of the aortic arch treated with the jailed coiling technique.
Methods
A retrospective review of 9 patients (mean age 70 years, 9 males) treated for PAUs and SAs of the aortic arch between 2018 and 2019 at our institution. Treatment included thoracic endovascular aneurysm repair (TEVAR) with a short (1cm) proximal landing zone, followed by coiling of aneurysm through a jailed extraluminal catheter.
Results
All 9 patients underwent TEVAR followed by jailed coiling of the lumen of the aneurysms. Debranching of supra-aortic vessels was performed in 4 patients in order to create a proximal landing zone of at least 10 mm. Technical success was achieved in all cases. Coils were placed accurately within the aneurysm lumen in all patients. No distal embolization occurred. One patient expired in the perioperative period from a cardiac event. No patient developed spinal cord ischemia or stroke in the perioperative period. Mean follow-up was 10 months (range 3-18). On follow-up imaging, complete thrombosis of the aneurysm lumen was seen in all patients. None experienced enlargement of ulcer dimensions and none required reintervention.
Conclusion
PAUs and SAs of the aortic arch with a very short landing zone can be treated successfully by jailed coiling of the aneurysm and TEVAR. The procedure is technically feasible and can be performed with minimal morbidity. Long-term durability of the repair needs to be determined.
