Patients should get a choice between open and endovascular surgery for aortic conditions, CX audience agrees

Clockwise from top left: Roger Greenhalgh (London, UK); Roberto Chiesa (Milan, Italy); Afshin Assadian (Vienna, Austria); Tilo Kölbel (Hamburg, Germany); and Thomas Gandet (Montpellier, France).

A decisive vote at CX Aortic Vienna 2021 (5–7 October, broadcast) revealed that 90% of the audience was in favour of offering patients a choice between open and endovascular surgery for aortic arch procedures. Edited cases from Thomas Gandet (Montpellier, France) and Tilo Kölbel (Hamburg, Germany) were among presentations that helped to inform this audience poll. The importance of providing both open and endovascular approaches was also raised in a discussion on aortic coarctation and by cardiac surgeon Martin Grabenwöger (Vienna, Austria) in a session on dissection.

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Gandet’s presentation outlined the Endo-Bentall procedure—a new endovascular treatment used in ascending aortic pathologies that was later described by moderator Afshin Assadian (Vienna, Austria) as the “final frontier” in this space. Gandet, a cardiac surgeon, was keen to stress the importance of collaboration between cardiac and vascular surgeons in optimising this complex procedure.

Registrants can view Gandet’s edited case on demand here.

Following this, Kölbel described an aortic arch repair with a three-branched stent graft, concluding that the procedure is feasible and that the use of a steerable sheath reduces cervical access trauma. He noted that, while there is not much published on the topic, short- and midterm outcomes from his own group, and those from Stéphan Haulon (Paris, France) and colleagues, have been “very positive” to date.

Registrants can view Kölbel’s edited case on demand here.

CX Aortic Vienna 2021 polling results

In addition to an earlier session debating the role the open elephant trunk technique can play in aortic arch challenges, which saw 100% of CX Aortic Vienna attendees vote in favour of this approach continuing to be taught, these edited cases formed the basis on which the audience decided that patients should be offered a choice between open and endovascular options.

Registrants can view the full session on demand here and here.

Further insight on this topic later came from W Anthony Lee (Boca Raton, USA), who presented an edited case detailing total endovascular repair of the aortic arch using the Relay triple-branch device (Terumo Aortic), and Kazuo Shimamura (Osaka, Japan), who discussed the possibility of reducing the risks of stroke and type 1 endoleak via the endovascular ‘chimney technique’ (Gore).

Registrants can view Lee’s edited case on demand here and Shimamura’s edited case on demand here.

A similar message regarding endovascular and open surgery options came from a separate session later in the day—one that was primarily focused on aortic coarctation. Konstantinos Spanos (Larissa, Greece) communicated that endovascular repair or coarctation is effective and has an acceptable safety profile, with balloon-expandable covered stents being the preferred device for these procedures. However, responding to a question from moderator Haulon on the role that remains for open surgery, Spanos also noted that much of the current literature states it is still preferred in complex heart anatomies like heart hyperplasia or extensive heart aneurysm in coarctation patients, adding that this is especially true of the European Society of Cardiology (ESC) guidelines from 2020.

Registrants can view Spanos’ presentation on demand here.

Discussion also turned to the importance of offering both open and endovascular solutions in a session on aortic dissection. Chair Roger Greenhalgh (London, UK) asked moderator Grabenwöger, a cardiac surgeon, his opinion on whether offering every patient the opportunity of both treatment options should become the norm in the future. “Yes,” he replied, detailing that, in his practice, Grabenwöger takes into account various factors when assessing a patient, including age. While he will choose open surgery for certain patients, he noted that for patients with a lot of comorbidities, he opts for partnering with his endovascular colleagues in the hybrid room. “Our hybrid room is located in our cardiac operation centre, and so also if there are any problems with vascular access we can help.”

Registrants can view the full session on demand here and here.


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