**3.1. Clinical case 1**

A 32-year-old female presenting cardiogenic shock (Figures 1-2).

Endoprosthesis deployment in the ascending aorta usually requires large diameter and long sheath. There is always possibility of damaging the aortic valve, since the nose of the com‐ mercially available devices is designed for descending and/or abdominal aorta. The vascular prosthesis should be large enough to oversize by 15-20 % the aortic diameter and short in length to fit between the coronary arteries and the brachiocephalic trunk. This length usually measures 8 cm or less. The endovascular technique would have several advantages over the open surgical alternatives if the right tools for the procedure were available. Current thoracic aortic stent-grafts are too long, while abdominal aortic stent-grafts are too short and narrow. Moreover, abdominal aortic delivery systems are too short to traverse the long and tortuous

Several different approaches have been presented and published over the last years as an attempt to solve very dramatic situations stretching the limits of the current technology [6-8].

The technique should be carefully planned. Rapid pacing and adenosine are useful to lower blood pressure and allow precise deployment. A rigid (Landerquist or super stiff) and long (260 cm) guidewire is usually placed in the left ventricle to give adequate support near the coronary arteries. This is similar to what we use when performing transcatheter aortic valve implantation (TAVI). One important tip is to perform a "wide J-shape" at the end of the rigid guidewire in order to prevent left ventricule perforation and, consequently, cardiac tamponade

Similar to other endovascular procedures, besides careful planning, patient selection and technical expertise are crucial to obtain satisfactory results. In this setting multidetector computed tomography (MDCT) plays an important role in selecting the patients suitable for

We have recently published a series of five clinical cases and described the technique in which the axillary artery was used to deliver the endograft for the treatment of different thoracic aortic diseases [9]. We also demonstrated the possibility of concomitant treatment of ascending

Transcarotid is another alternative access and, recently, transapical approach through a small

In this part we will discuss clinical cases of endovascular treatment of ascending aortic diseases

the procedure and allows a careful and detailed step by step preoperative planning.

path from the femoral artery to the ascending aorta.

aorta disease and coronary stent implantation [10,11].

or left ventricular pseudoaneurysm.

414 Artery Bypass

left thoracotomy has been described.

showing different approaches and techniques.

A 32-year-old female presenting cardiogenic shock (Figures 1-2).

**3. Clinical cases**

**3.1. Clinical case 1**

**Figure 1.** Aortogram showing bovine trunk and a pseudoaneurysm in the anterolateral wall of the ascending aorta 1 cm above the ostium of the right coronary artery.

**Figure 2.** Final aortogram of emergency endovascular correction of a pseudoaneurysm through transfemoral implan‐ tation of a Cook endoprosthesis. The shorter device we had available was a 8 cm length endoprosthesis. In order to preserve flow in the brachiocephalic trunk and left carotid artery (bovine trunk) we had to use a chimney (snorkel) technique in this two vessels arch using two Viabahns to preserve flow.

### **3.2. Clinical case 2**

A 57-year-old female underwent coronary artery bypass graft in another hospital with left internal mammary artery to the left anterior descending and saphenous vein graft to the right coronary artery. The patient developed mediastinitis and had 7 reinterventions resulting in acute bleeding through the sternum. She was sent to our hospital in cardiogenic shock and manual compression of the bleeding site in the sternum. Previous computed tomography showed ruptured pseudoaneurysm at the proximal anastomosis of saphenous vein graft to the (Figures 3-6).

**Figure 4.** Right coronary angiography demonstrating severe stenosis. Once saphenous vein graft to the right coronary

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417

artery had occluded by the endoprosthesis, the native right coronary artery had to be treated.

**Figure 5.** Deployment of three stents in the right coronary artery.

**Figure 3.** Emergency endovascular deployment of two abdominal extension cuffs (Gore-Tex) in the ascending aorta between the coronary ostium and the brachiocephalic trunk through the left axillary artery. The bleeding stopped im‐ mediately and the patient became stable.

**Figure 4.** Right coronary angiography demonstrating severe stenosis. Once saphenous vein graft to the right coronary artery had occluded by the endoprosthesis, the native right coronary artery had to be treated.

**Figure 5.** Deployment of three stents in the right coronary artery.

**3.2. Clinical case 2**

416 Artery Bypass

(Figures 3-6).

A 57-year-old female underwent coronary artery bypass graft in another hospital with left internal mammary artery to the left anterior descending and saphenous vein graft to the right coronary artery. The patient developed mediastinitis and had 7 reinterventions resulting in acute bleeding through the sternum. She was sent to our hospital in cardiogenic shock and manual compression of the bleeding site in the sternum. Previous computed tomography showed ruptured pseudoaneurysm at the proximal anastomosis of saphenous vein graft to the

**Figure 3.** Emergency endovascular deployment of two abdominal extension cuffs (Gore-Tex) in the ascending aorta between the coronary ostium and the brachiocephalic trunk through the left axillary artery. The bleeding stopped im‐

mediately and the patient became stable.

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

**Figure 8.** Computerized tomographic angiography showing a 3.4-cm pseudoaneurysm with partial thrombosis in as‐

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419

**Figure 9.** A) Intravascular ultrasound of left main artery evidencing significant stenosis due to calcified plaque. (B) In‐ travascular ultrasound measurements confirming the presence of a large left main artery and significant plaque bur‐

Both procedures were successfully performed and the patient was discharged without (Figures 10-12). At 6 months and 1 year clinical follow-up the patient had no symptoms as well as no

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

den. (C) Virtual histology showing predominantly fibrous plaque and superficial calcium arch.

cending aorta and surrounding intramural hematoma.

other adverse cardiovascular events.

**4. Target diseases**

#### **3.3. Clinical case 3**

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

**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 suggesting dissection at the saphenous vein graft ostium.

**Figure 8.** Computerized tomographic angiography showing a 3.4-cm pseudoaneurysm with partial thrombosis in as‐ cending aorta and surrounding intramural hematoma.

**Figure 9.** A) Intravascular ultrasound of left main artery evidencing significant stenosis due to calcified plaque. (B) In‐ travascular ultrasound measurements confirming the presence of a large left main artery and significant plaque bur‐ den. (C) Virtual histology showing predominantly fibrous plaque and superficial calcium arch.

Both procedures were successfully performed and the patient was discharged without (Figures 10-12). At 6 months and 1 year clinical follow-up the patient had no symptoms as well as no other adverse cardiovascular events.
