Aortic interventions can be divided mainly in three categories:
- open repair surgery
- endovascular repair
- hybrid procedures.
Open repair surgery
Open repair surgery involves replacement of the aorta with a graft usually composed of synthetic polyester. Graft can be placed either through an interposition graft or an inclusion graft (Fig. 1 Fig. 2).
The most common use of open repair surgery is for treatment of ascending aortic diseases, as this segment is not usually suited for endovascular treatment.
Open repair surgery of the ascending aorta usually includes:
- reconstruction of the ascending aorta by a supracoronary graft, with or without positioning of an aortic valve prosthesis (Wheat procedure)
- replacement of the ascending aorta, aortic root and aortic valve by a composite graft, with reimplantation of the coronary arteries in the graft (Bentall procedure) (Fig. 3 Fig. 4 Fig. 5).
Other less common procedures include:
- The Cabrol procedure, which includes replacement of the ascending aorta and aortic valve by a composite graft. Moreover, a smaller tube graft is then anastomosed to the left and right coronary ostia in an end-to-end manner. Finally, the coronary graft is anastomosed to the aortic graft in a side-to-side manner (Fig. 6).
- Aortic valve - sparing procedures (Yacoub and David techniques).
- Biologic grafts (Ross procedure).
Another approach is elephant trunk technique, first introduced by Borst in 1983. This procedure involves the replacement of the ascending aorta and aortic arch. Moreover, a prosthetic limb (elephant trunk) is left afloat in the descending aorta. This technique had the advantage of a graft already present in the descending aorta which can be used for aortic reconstruction at a later stage (Fig. 7).
Thoracic and abdominal endovascular aortic repair (TEVAR/EVAR) is an alternative to open surgical treatment and widely applied, due to excellent clinical results. Both procedures use a retrograde approach through the femoral arteries.
A correct choice of the length of the endograft and identification of appropriate proximal and distal landing zones are crucial for TEVAR planning. (Fig. 8).
In cases where is no adequate landing zone from the ostium of the left subclavian artery, a de-branching procedure is needed to ensure side-branch circulation. A common procedure is carotid-subclavian bypass (Fig. 9).
The implantation of an endograft of abdominal aorta requires detailed preoperative length and diameter measurements and accurate longitudinal device placement (Fig. 10).
The hybrid procedures are a less invasive form of open repair surgery combined with endovascular approach. They involve arch de-branching, thereby creating a proximal landing zone of adequate length, followed by stenting over the aortic arch (Fig. 11 Fig. 12 Fig. 13). Among them there is the so-called frozen elephant trunk technique. This approach involves the use of a device featuring two components: a proximal Dacron tube and a distal polyester and nintinol stent. The proximal tube is used for arch reconstruction. The distal stent is deployed in the descending aorta (Fig. 14 Fig. 15).
CT angiography (CTA) is the most performed modality in the assessment of postoperative aorta because of high temporal and spatial resolution combined with multiplanar and 3D reformation capabilities.