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The patient was a 69-year-old female with an extensive smoking history, chronic obstructive pulmonary disease (COPD), a prior aorto-bifemoral bypass, and atrial fibrillation who presented after a recent hospitalization for staphylococcal bacteremia. She were admitted with what was initially thought to be a COPD exacerbation. Just before admission, laboratory results were significant for a C-reactive protein (CRP) of 51, an erythrocyte sedimentation rate (ESR) of 74, and a procalcitonin level of 0.06. Further workup included a computed tomography (CT) scan of the chest, abdomen, and pelvis, which showed two ascending aortic pseudoaneurysms, as seen in the axial CT. One originated from the ascending aorta anteriorly, while the other was located on the patient's left side from the ascending aorta. This 3D reconstruction image further displayed the two ascending aortic pseudoaneurysms. In addition to the pseudoaneurysms, there appeared to be a fistulous connection between the main pulmonary artery and the ascending aorta at the degenerated site, as shown in this axial CT cut. A preoperative echocardiogram demonstrated right ventricular dilation with septal bounce, indicating pulmonary hypertension that was likely related to the aorto-pulmonary fistula. 
 
Due to the patient’s numerous comorbidities, as listed on this slide, including respiratory failure requiring five liters of oxygen by nasal cannula, acute congestive heart failure due to right-to-left shunt, deconditioning that required the use of a wheelchair, pulmonary hypertension as discussed earlier, and volume overload with bilateral pleural effusions, the surgeons determined that the patient would be a poor candidate for open surgical repair. Due to this, they engaged in shared decision-making with the patient and arrived at the plan to pursue an ascending aortic thoracic endovascular aortic repair (TEVAR) to treat the aortic pathology.  

The key measurements needed to successfully plan this operation included the distance between the highest coronary artery and the innominate artery, measured along the greater and lesser curves of the aorta, along with the centerline of flow of the aorta. In addition, the proximal and distal landing zone diameters must be assessed, planning for approximately 15 to 20 percent oversizing of the TEVAR stent by diameter. The proximal and distal landing zones were measured with centerline cross-sections of the aorta. The proximal landing zone was approximately 26 x 30 mm, and the distal zone was similar at 24 x 31mm. The length between the landing zones was approximately 80 mm in the centerline and 100 mm along the greater curve. Due to this, the surgeons determined that the ascending aorta would likely accommodate a 10 cm conformable graft with a 34 mm diameter to reach the approximate 15 to 20 percent oversizing. 
 
In the operating room, the patient underwent open right groin exposure of the prior aorto-bifemoral graft and right ileo-femoral balloon angioplasty to secure appropriate endovascular access. The initial aortogram showed rapid filling of the pulmonary vasculature with aortic injection. The patient’s initial pulmonary artery pressure was 45 mmHg preoperatively, indicating the severity of this fistula causing pulmonary hypertension. Ascending TEVAR was then performed under rapid transvenous pacing to exclude the pseudoaneurysm. The initial aortogram was used to demarcate the origins of the highest coronary artery and the innominate artery to precisely deploy the stent between these landmarks. The completion aortogram displayed exclusion of the aneurysm without any filling of the pulmonary arterial tree. The coronary and innominate arteries each filled briskly. 
 
Postoperatively, the patient’s pulmonary artery pressures dropped from 45 mmHg to 19 mmHg immediately after stent deployment, indicating exclusion of the aorto-pulmonary fistula. Extubation was on postoperative day one, and the patient was transferred to the step-down unit on postoperative day three. Her congestive heart failure and pulmonary edema both improved with diuretics. A peripherally inserted central catheter (PICC) was placed with a plan for an extended regimen of outpatient intravenous (IV) antibiotics. The patient was discharged home on postoperative day five, on two liters of oxygen, with activity down from five liters preoperatively. The patient’s right-sided preoperative pleural effusion had also improved.  

At the postoperative clinic visit, the patient was doing well and was able to walk with a walker for long distances without needing a wheelchair. The patient continued on IV antibiotics, with the infectious disease team planning a six-week treatment course, and supplemental oxygen only as needed. 

At the follow-up nearly five months after the initial operation, the patient was doing well and did not require any supplemental oxygen. The patient was fully ambulatory within the home and had completed a course of IV antibiotics postoperatively, and the surgeons planned to keep the patient on lifelong suppressive oral antibiotics. By this visit, the patient’s inflammatory markers had nearly normalized, with a CRP of 4.6 and an ESR of 48. 

Some key takeways from this case include that an ascending TEVAR may be an option for the repair of ascending aortic pathology in patients who are poor candidates for open surgery. It can be considered either a bridge to definitive repair or a definitive treatment in some cases. The authors reviewed the key sizing principles for planning an ascending TEVAR, including the proximal and distal landing zone diameters, with an inclusion of approximately 20 percent oversizing, along with minding the space between the highest coronary artery and the innominate artery using greater and lesser aortic curvature, along with centerline measurements. Finally, rapid transvenous pacing is a key part of accurate TEVAR deployment in this area of the aorta. 
 
The ARISE trial investigated the early feasibility and safety of the GORE Ascending Stent Graft, which was placed in 19 patients with successful delivery and deployment in all cases. The ARISEII trial is currently ongoing to evaluate the safety and effectiveness of the ascending aortic stent for the treatment of ascending aortic lesions, such as fusiform and saccular aneurysms, pseudoaneurysms, and penetrating aortic ulcers. 

References

1. Roselli EE, Atkins MD, Brinkman W, et al. ARISE: First-In-Human Evaluation of a Novel Stent Graft to Treat Ascending Aortic Dissection. J Endovasc Ther. 2023;30(4):550-560.

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