Joseph Coselli (Houston, USA) and Rodney White (Torrance, USA) led the discussion on treatment options for the aortic arch zones 0,1,2,3 in a CX Aortic Vienna (8–11 September, virtual) session that covered a broad range of techniques.
This session, and all other sessions from day one of CX Aortic Vienna, is available to view on demand. Click here to register and access the recording.
“We may say that the endovascular approach is evolving,” said Santi Trimarchi (Milan, Italy) discussing thoracic endovascular stent graft repair for ascending aortic diseases. Trimarchi noted that although surgical repair is considered the gold standard for the treatment of ascending aortic diseases, overall mortality can be up to 15% in high risk patients. Patients with prohibitive surgical risk who are not candidates for open procedures may be considered for Ishimaru Zone 0 thoracic endovascular aortic repair (TEVAR), Trimarchi said, before detailing the evolution of endovascular treatment in acute and chronic ascending aortic diseases. “[Endovascular repair] is already a reality in the treatment of ascending aortic diseases, both acute and chronic” he commented. Anatomy is the major drawback for endovascular management of the ascending aorta, Trimarchi acknowledged, commenting that technological evolution is needed to overcome this limitation.
Next to speak was Jean Porterie (Toulouse, France), who discussed new evidence and updated outcomes with the frozen elephant trunk (FET) technique. He concluded that this is a “safe and effective solution,” favouring aortic remodelling and decreasing the rate of aortic-related events. He added that the approach allows for single-stage therapy in well-selected patients and provides an ideal landing zone for potential thoracic endovascular aortic repair (TEVAR) completion.
Stéphan Haulon (Paris, France) then spoke on total endovascular treatment of the aortic arch. He detailed that a multicentre global experience demonstrates the technical feasibility and safety of total endovascular aortic arch repair for aneurysms and chronic dissection using three-vessel inner branch stent grafts. In addition, mortality and stroke rates compare favourably to reported outcomes of total open surgical arch replacement, particularly among higher risk patients who had prior median sternotomies and ascending aortic repairs. At 31%, the high rate of secondary interventions emphasises the need for larger experience and longer follow-up, Haulon remarked.
Thomas Wyss (Winterthur, Switzerland) gave participants a detailed overview of the key messages from the expert consensus document compiled by the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) covering options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch. The document includes 41 recommendations from a multidisciplinary group covering all aspects of aortic arch disease. “The aortic arch is neither exclusively for cardiac, nor for vascular surgeons,” commented Wyss in his presentation. “[The] best aortic arch treatment calls for interdisciplinary methods, so we need to eliminate borders and work together,” he added.
On the topic of endovascular management of aortic coarctation, Frank Arko (Charlotte, USA) discussed the role of self-expanding stents for best long-term outcomes. He concluded that aortic coarctation can be successfully treated with thoracic stent grafts and that the benefits continue beyond the initial resolution of symptoms. In addition, Arko specified that the treatment should be performed at a high-volume centre with a multispecialty approach.
Concluding the session, Jean-Marc Alsac (Paris, France) offered results of the French REP study, a prospective, multicentre, pilot study evaluating the efficacy and safety of a custom-made thoracic stent-graft with proximal scallop for use in the aortic arch. The concept of the scallop is to increase the proximal sealing zone in the curvature of the arch without covering supra aortic trunks, he explained. Detailing the findings of the study, he noted that the scallop has a number of potential advantages including no cannulation or snaring of wires, and could be considered as a valuable design option for TEVAR in the aortic arch.
