Endovascular repair of the ascending aorta in the Vascular Quality Initiative

Abstract

Objective: Endovascular repair of ascending aortic disease represents a last resort alternative for patients at high-risk for open surgery. The aim of this study was to describe outcomes of patients undergoing endovascular repair of the ascending aorta in a large international registry. Methods: We retrospectively analyzed patients in the Vascular Quality Initiative who underwent endovascular repair isolated to the ascending aorta between 2013 and 2022. Patients with innominate artery treatment or missing data on this variable were excluded. Primary outcomes were in-hospital and perioperative mortality. Secondarily, we assessed in-hospital complications and reinterventions and 3-year mortality with Kaplan-Meier methods. Subset analyses stratified the cohort based on prior aortic surgery and aortic pathology. Results: We identified 44 patients treated at 19 centers, with a median age of 76 years (interquartile range, 66-85 years), and 21 (48%) were males. Pathologies were aortic dissection (acute, 36%; chronic, 11%), penetrating atherosclerotic ulceration (PAU) (16%), PAU with intramural hematoma (2.3%), pseudoaneurysm (11%), post-dissection aneurysm (9.1%), and degenerative fusiform (6.8%) or saccular aneurysm (6.8%). Twenty-six patients (59%) presented symptomatic and two with rupture (4.5%). Almost one-half of procedures were performed within 24 hours (20%) or 4 hours (23%) of presentation or acute decompensation. Twenty-four patients (55%) had groin-access alone, and 13 patients (30%) had supra-aortic trunk access. Eight patients (18%) had >1 device implanted. In-hospital and perioperative mortality were 23% and 27%, respectively. Intraoperatively, there was one (2.3%) type IB endoleak and one (2.3%) conversion to sternotomy. Fourteen patients (32%) had 20 postoperative complications, consisting of acute kidney injury (14%), pulmonary (11%) or cardiac (6.8%), reinterventions (6.8%), stroke (2.3%), dialysis (2.3%), or leg ischemia (2.3%). Estimated 3-year mortality was 40%. Subset analyses found no perioperative mortality in patients with prior aortic surgery (16%), pseudo- or degenerative aneurysm (25%), or PAU with intramural hematoma (2.3%). Differently, perioperative mortality for aortic dissection, postdissection aneurysm, and PAU were 48%, 25%, and 14%, respectively. Estimated 3-year mortality rates differed per pathology group (dissection-related, 52%; PAU, 37%; aneurysm, 17%). Conclusions: Endovascular repair of the ascending aorta is rarely performed, seems technically feasible, but is associated with considerable perioperative morbidity and mortality. The underlying pathology likely influences outcomes in these high surgical risk patients. Perioperative mortality for aortic dissection is similar to prior reports of medically managed type A aortic dissection. Future research with larger sample sizes is required to determine clinical safety of this procedure and could focus on the development of a dedicated ascending aorta stent graft.