Total Endovascular Repair of Ascending Aortic Pathology: The ENDOASC Multicentre Global Study

The role of endovascular repair of the ascending aorta remains questionable due to anatomic and technical constraints, particularly at the proximal landing zone. Whether thoracic endovascular aortic repair (TEVAR) for the ascending aorta is safe and feasible has not been evaluated previously in a large multicentre study. This study aimed to evaluate the feasibility and safety of endovascular repair of pathologies affecting the ascending aorta.

An international, multicentre, retrospective study was conducted following the STROBE guidelines including patients who underwent ascending TEVAR (2011 - 2024) for zone 0 aortic pathologies. Primary outcomes were technical success, thirty day death, and re-interventions. Secondary outcomes were survival and re-intervention during follow up analysed using Kaplan-Meier estimates, and post-operative imaging findings, including endoleaks and sac dynamics.

Fifty-eight patients (median age 75 years [interquartile range 65, 80]; 26 [45%] women) underwent ascending TEVAR across 17 centres for dissections (n = 18; 31%), non-dissection native pathologies (n = 18; 31%), and post-surgical pseudoaneurysm (n = 22; 38%). Of these, 36% (n = 21) were treated urgently. Technical success was 83% (n = 48), with a thirty day mortality rate of 10% (n = 6) and a re-intervention rate of 12% (n = 7). Median follow up was 11 months. Kaplan-Meier survival at 12 months was 55% (standard error [SE] 0.12) for dissections, 76% (SE 0.10) for non-dissection pathologies, and 77% (SE 0.10) for post-surgical pseudoaneurysms (log rank, p = .34). Freedom from re-intervention at 12 months was 71% (SE 0.13), 94% (SE 0.05), and 70% (SE 0.10), respectively (log rank, p = .27). The estimated re-intervention free survival for the total cohort was 78% (SE 0.06).

Despite current technical limitations that challenge endovascular repair of the ascending aorta, TEVAR for ascending pathologies may be performed with acceptable mortality and re-intervention rates in selected cases deemed unfit for open repair. Development of dedicated devices might increase the applicability of endovascular repair for ascending aortic pathologies and improve outcomes.