**4. Target diseases**

**Figure 6.** Computed tomography showing the two extension cuffs in the ascending aorta and the three stents in the

A 74-year-old male with previous coronary artery bypass graft presented with iatrogenic ascending aortic pseudoaneurysm that occurred during angiography. The patient was at very

**Figure 7.** A) Coronary angiogram showing left main bifurcation with severe stenosis and circumflex with severe steno‐ sis extending to large marginal branch. (B) Aortic angiogram demonstrating ascending aorta dilatation and image

high risk for surgical treatment, therefore an (Figures 7-9).

suggesting dissection at the saphenous vein graft ostium.

right coronary artery.

418 Artery Bypass

**3.3. Clinical case 3**

There are several pathologies of the ascending aorta that can be potentially addressed by the endovascular approach. Pseudoaneurysms or sacular aneurysms in the mid-ascending aorta are adequate for this technique because they usually appear with a sufficient proximal and

**Figure 10.** Coronary angiogram showing final result in right anterior oblique projection (A) and spider view (B).

those patients not eligible for conventional intervention due to co-morbidity or severe

Endovascular Treatment of Ascending Aorta: The Last Frontier?

http://dx.doi.org/10.5772/55149

421

**Figure 12.** Computerized tomographic angiography showing final result after endoprosthesis deployment.

Thoracic stent grafting in the ascending aorta presents specific challenges and the role of uncovered stents is unclear in this situation. The majority of patients with acute type A aortic dissection has the intimal tear originated in the sinotubular junction. More than 90% of patients with this disease does not have sufficient proximal or distal landing zone required for secure fixation. Therefore, the site of the intimal tear as well as aortic valve insufficiency and aortic diameter >38mm are major factors limiting the use of endovascular therapy for acute type A dissection. Current available stents in use to treat type B aortic dissection do not address anatomical constraints present in type A aortic dissection in the majority of cases, hence the

Endovascular approach of the ascending aorta has several limitations and is still in its

The diameter of the ascending aorta is usually larger than the rest of the aorta and the proximity with the aortic valve and the presence of the coronary arteries pose special challenges.

The length of the delivery system, which is designed for the abdominal aorta, does not allow

complications of the disease.

development of new devices is required.

to reach the ascending aorta through the groin.

**5. Technical limitations**

beginning phase.

**Figure 11.** (A) Ascending aorta angiogram before endoprosthesis deployment showing a large pseudoaneurysm (yel‐ low arrow). (B) Ascending aorta angiogram after endoprosthesis deployment evidencing sealed pseudoaneurysm and a type 1 endoleak (red arrow).

distal landing zone. On the other hand, fusiform aneurysms have the limitation of lacking a sufficient landing zone in many cases.

Thoracic endovascular stent grafting has revolutionized the treatment of distal [type B] acute aortic dissection. Endovascular surgeons are now seeking the ways to improve the treatment of type A dissection by offering endovascular techniques to replace conventional surgical therapy. Less invasive endovascular therapy, obviates the need for sternotomy and cardio‐ pulmonary bypass, reduces perioperative morbidity, and offers an alternative solution for

**Figure 12.** Computerized tomographic angiography showing final result after endoprosthesis deployment.

those patients not eligible for conventional intervention due to co-morbidity or severe complications of the disease.

Thoracic stent grafting in the ascending aorta presents specific challenges and the role of uncovered stents is unclear in this situation. The majority of patients with acute type A aortic dissection has the intimal tear originated in the sinotubular junction. More than 90% of patients with this disease does not have sufficient proximal or distal landing zone required for secure fixation. Therefore, the site of the intimal tear as well as aortic valve insufficiency and aortic diameter >38mm are major factors limiting the use of endovascular therapy for acute type A dissection. Current available stents in use to treat type B aortic dissection do not address anatomical constraints present in type A aortic dissection in the majority of cases, hence the development of new devices is required.
