Hybrid Arch Aneurysm Repair With Ascending Aortic Wrap and TEVAR.

Introduction: Management of patients with large aortic arch aneurysms who are considered high risk for frozen elephant trunk technique have been challenging, especially when they have a dilated ascending aorta (AA) that precludes total endovascular branched repair (arch BEVAR). A viable option in our armamentarium is wrapping of the AA (AW), and zone 0 Ishimaru TEVAR.

Methods: Retrospective analysis of our aortic database from 2013 to 2024 to select high-risk patients with aortic arch aneurysm that had an AW and TEVAR. We performed CTA analysis before and after wrapping and TEVAR, and last available CTA. The primary end points were 30-day mortality and stroke.

Results: A total of 12 patients had AA wrap and TEVAR, with supra-aortic vessels (SAVs) debranching (open or endovascular). In 9 patients, the indication for treatment was a large arch atherosclerotic aneurysm, and in 3 patients a dissecting arch aneurysm depicted during follow-up of AW initially performed for acute type A dissection (51.5 months on average between the wrap and the TEVAR). Average age was 72.9 years. Ascending aorta wrap and TEVAR were performed concomitantly in 3/12 patients, including 2 patients with rupture. It was staged in the other 9 patients. The average diameter of the AA pre-wrap was 47.7 (41.3-57), and post-wrap 35.6 (31.9-43) mm. The wrap provided an average seal length of 68.5 (38.4-97.4) mm. A total of 34 SAV were successfully debranched. No type 1 or 3 endoleaks were depicted on completion angiogram. Within the first 30 days, no strokes were diagnosed, and 1 patient with Horton disease died of cardiac arrest on postoperative day 7. Three patients required early reinterventions, including redosternotomy in 2 patients. Mean follow-up (FU) was 28 months (1-75). During FU, 1 patient developed a left vertebral artery steal phenomenon requiring a carotid subclavian bypass, and another patient died of an unknown cause.

Conclusion: Ascending aorta wrap technique with debranching of the SAVs and zone 0 TEVAR might be a good option in patients at high risk for open replacement of the AA and with unfavorable proximal seal zone for a total endovascular repair.

Clinical impact: In the current study, we describe the treatment of aortic arch aneurysms in patients considered at high risk for open replacement of the aortic arch and also not candidate for complete endovascular arch repair (arch BEVAR). Ascending aorta wrap with surgical or endovascular debranching of SAVs and zone 0 TEVAR was performed in 12 patients with favorable outcomes. It should thus be considered a treatment option in this subset of fragile patients with unfavorable proximal seal zone for total endovascular repair. This technique does not require cardiopulmonary bypass (CPB) support, neither aortic cross-clamping.