Feasibility Of Total Endovascular Aortic Arch Exclusion After Surgery For Type A Acute Aortic Dissection: Why Aren’T All Patients Eligible?
AUGUSTO D'ONOFRIO, Giorgia Cibin, Elisa Gastino, Irene Cao, Michele Antonello, Gino Gerosa.
UNIVERSITY OF PADOVA, PADOVA, Italy.
BACKGROUND:Total endovascular aortic arch exclusion (TEX) has shown to be a safe and effective option in high-risk patients requiring treatment for arch pathologies, especially after surgery for type A acute aortic dissection (TAAD). In this scenario, the main challenges for TEX feasibility are represented by anatomical issues that often derive from the technical aspects of the first operation. Therefore, they should be considered when performing surgery for TAAD in order to prepare patients for a potential future treatment by means of TEX. Aim of this retrospective, single center study was to evaluate CT-scans of patients after surgery for TAAD in order to assess how many of them would be suitable potential candidates for TEX and what are the reasons for being unsuitable. METHODS: We analyzed early post-operative CT-scans of patients who underwent ascending aorta (with or without hemiarch) replacement for TAAD at our institution. Patients who underwent procedures on the aortic arch, either partial or complete, were excluded. The device considered in this study for TEX technical feasibility was a single-branch, off-the shelf, bimodular stent-graft. The following anatomical and technical aspects were evaluated: proximal landing zone in a vascular graft (size and length of the inner and of the outer curvature, presence of kinking, coronary ostia height); distal landing zone and potential for additional stent implantation; shape of the aortic arch; size, length, pathology and take-off angle of supra-aortic vessels. RESULTS: From January 2007 to October 2021, a total of 189 patients underwent ascending aorta replacement for TAAD at our institution. Post-operative CT-scans were unavailable or inadequate for 116 (61.4%) patients. The remaining 73 patients (38.6%) had their CT scan analyzed for TEX suitability and represent the population of our study. Suitable patients for TEX were 38 (52.1%) while 35 (47.9%) were deemed unsuitable. Reasons for unsuitability were: short ascending aortic graft in 10 (28.6%), kinking of the ascending graft in 3 (8.6%), inadequate landing zone in the supra-aortic vessels for the device branch (dissection, inadequate length and/or diameter) in 30 (85.7%), inadequate take-off angle in 4 (11.4%) and inadequate distal landing zone in 6 (17.1%). In some cases there were more issues that made TEX not feasible. Overall, 11 (31.4%) patients were unsuitable due to technical aspects of the first operation. CONCLUSIONS: Our data show that aortic arch stent grafting after surgery for type A acute aortic dissection is potentially feasible in nearly 50% of patients. A careful intraoperative management during surgery for TAAD aimed at preparing the patient for a potential future TEX in case of progression of the disease might help to increase the feasibility rate and eventually to give patients an endovascular option for future treatments. 
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