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The patient was a 63-year-old man with multiple comorbidities who was transferred to the authors’ facility in cardiogenic shock after a non-ST-elevation myocardial infarction (NSTEMI) with a type A dissection. He also presented with evidence of renal, hepatic, and neurological dysfunction, which were unexplained by the focal dissection showing patent true and false lumens, as well as no evidence of tamponade or any dissection involving the aortic root, valve, or coronaries.  

A decision was made to not offer any surgical intervention due to the futility of surgical treatment in correcting his current shock state. The patient was managed medically, including impulse control therapy in the Cardiothoracic Intensive Care Unit (CTICU). Over a 12-day period, his mental status, shock liver, and renal failure began to improve. He became consent-able and understood that his numerous comorbidities and acute illness made him a poor candidate for surgical repair. As a result, transcatheter aortic valve replacement (TEVAR) stenting of the ascending aorta was performed as a lifesaving compassionate use.  

Given the prolonged initial hospitalization, a repeat computed tomography angiography (CTA) was performed to confirm no interval progression of the dissection. A detailed 3D computed tomography (CT) reconstruction and extensive review were required to determine the anatomic feasibility of the procedure. Measurements were taken for the proximal landing zone at the sinotubular junction, the distal landing zone, and the distance from the highest coronary artery to the innominate artery. A commercially available 4.5 x 10 cm stent graft was chosen for the procedure. 

Access to the right common femoral artery and right common femoral vein was obtained for angiogram and stent deployment, and the transvenous pacing wire was placed. Intravascular ultrasound pullback images were obtained, confirming rue lumen access in the ascending aorta with dissection extending from the sinotubular junction (STJ) to the innominate artery. No distal dissection was identified in the descending thoracic aorta.  

A diagnostic aortogram was performed to verify the anatomy, which was similar to that seen on the 3D CT reconstruction. The aortogram was used to mark anatomical landmarks on the screen for precise device deployment, ensuring that there was no coverage of the most superior coronary or the innominate artery. The device was partially deployed to 50 percent to conform to the ascending aortic curvature.  

A repeat aortogram was conducted to confirm the device positioning in relation to the coronary ostia and the innominate artery. The ascending aortic device was completely deployed successfully with transvenous rapid pacing. The completion angiogram demonstrated a well-positioned stent graft with widely patent coronary arteries and arch vessels, and successful exclusion of the type A dissection with no endoleak. 

The patient was taken to the CTICU on inotropic support. The patient was extubated on postoperative day one and was off inotropic support by postoperative day two. The patient was downgraded from the ICU on postoperative day three and discharged on postoperative day eight. His postoperative echocardiogram revealed a left ventricular ejection fraction of 69 percent, and his CT scan showed optimal stent positioning without endoleak.  

Five months postoperatively, he presented with decompensated congestive heart failure (CHF) and uncontrolled hypertension in the setting of cocaine and methamphetamine use, and he had developed a Type 1B endoleak. He was found to have a massive 13.5 cm ascending aortic pseudoaneurysm displacing the heart to the left. Coronal and sagittal cuts displayed the enormity of the pseudoaneurysm. Given the development of the massive pseudoaneurysm, the decision was made to offer the patient definitive surgical repair. At this point, he had moderate to severe aortic insufficiency (AI) and an ejection fraction of 45 percent. 

Definitive surgical repair required unique case planning. Given the massive pseudoaneurysm and the inability to cross-clamp the ascending aorta, an axillary cannulation strategy was chosen. An oscillating saw was needed for safe sternal reentry, and the ascending stent graft needed to be removed for definitive repair. Therefore, the team decided to proceed with deep hypothermic circulatory arrest with antegrade cerebral perfusion. Another challenge involved ensuring adequate myocardial protection due to the massive pseudoaneurysm, as there was no direct access to the coronary arteries or coronary sinus for cardioplegia delivery until after the stent graft was explanted. Consequently, direct coronary ostial cardioplegic administration was chosen. In case of left ventricular (LV) distention due to moderate to severe AI, plans were made for possible LV apical venting, due to no pulmonary vein access.  

The procedure began with right axillary arterial and femoral venous cannulation. A right axillary incision was made, and a 10 mm graft was sutured to the artery using 6-0 Prolene suture in a running fashion. The graft was then connected to cardiopulmonary bypass. Next, a midline sternotomy was performed using an oscillating saw. The innominate vein and artery, along with the left common carotid artery, were snared for antegrade cerebral perfusion. Cardiopulmonary bypass was initiated, and cooling was employed to achieve deep hypothermia to a core temperature of 18 degrees Celsius. Upon opening the pericardium, loss of domain was noted due to the massive pseudoaneurysm. The chronic aortic dissection was densely adhered to the pericardium, causing both the right and left ventricles to be pushed to the left and posteriorly within the thoracic cavity.  

Once the goal temperature was reached, the pseudoaneurysm was opened, and unilateral antegrade cerebral perfusion was maintained via the snared innominate and left common carotid arteries. The ascending aortic pseudoaneurysm was excised, and the stent graft was explanted. The bilateral coronary ostia were dissected and identified for handheld cardioplegia delivery. The proximal transverse arch was resected and replaced in an extended hemi-arch fashion.  

For the distal anastomosis, a 28 mm fabric graft was selected and anastomosed to the proximal arch using running 4-0 Prolene suture, which was buttressed with a felt sandwich. Corporeal perfusion was resumed after the open distal anastomosis. The aortic graft was deaired, and full flow was resumed. Rewarming was then initiated. The aortic root was dissected, and aortic root repair was performed with aortic valve resuspension using three pledgetted sutures at each commissure. The proximal anastomosis of the 28 mm Dacron graft to the supra-coronary ascending aorta was completed using 4-0 Prolene in a running fashion.  

Following this, the cross-clamp was removed, and spontaneous sinus rhythm resumed. The patient was weaned from cardiopulmonary bypass without issue. His severe AI improved to mild after the procedure. The patient was extubated in the CTICU on postoperative day one and was off inotropic support by postoperative day three. He was downgraded from the ICU on postoperative day four and discharged on postoperative day seven.  

The patient remained stable six months postoperatively. A CT scan prior to discharge showed a successful surgical aortic repair without residual pseudoaneurysm. The patient was seen in the clinic at three and four months postoperatively with repeat imaging. Although he was attempting drug rehabilitation, he was readmitted twice since surgery due to hypertensive urgency and stimulant drug use. Nonetheless, he returned to his baseline standard of living and exercise tolerance. His four-month postoperative imaging showed stable postoperative changes. 

In conclusion, ascending TEVAR can be used as an alternative treatment for type A aortic dissection in patients with suitable anatomy who are poor candidates for open surgical repair. This approach may serve as either definitive treatment or as a bridge to surgery, as demonstrated in this case. Open surgical repair remains the gold standard therapy for Stanford type A aortic dissection.  

The ARISE III trial is an ongoing pivotal multicenter trial evaluating the use of ascending TEVAR in cases of type A dissection. Aortic arch repair is complicated in patients with chronic aortic dissection and previous endovascular repair, especially in the presence of a massive pseudoaneurysm. Therefore, careful planning is required when choosing strategies for cannulation, cardioplegia, and cerebral protection.  

Given the ongoing clinical trials for ascending aortic stent devices, the number of patients who have undergone ascending TEVAR as a bridge to surgical repair will likely increase. This will require carefully planned, complex procedures for the definitive treatment of their aortic disease. 

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