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<\/p>\nThe Endo-Wheat procedure represents an innovative, minimally invasive endovascular approach for the treatment of acute aortic syndromes and type A aortic dissection. Historically, type A dissection has been considered one of the most critical, technically challenging, and high-mortality emergencies in cardiovascular surgery, with open surgical reconstruction remaining the gold standard. However, in certain patient populations\u2014particularly the elderly, those with severe comorbidities, or patients in critical condition\u2014traditional surgery involving cardiopulmonary bypass and hypothermic circulatory arrest is associated with extremely high risks. In response to this clinical challenge, the concept of the Endo-Wheat procedure was developed as a hybrid and endovascular alternative to the classic open Wheat operation.<\/p>\n
The classic, open surgical Wheat procedure, first described in 1964, involves separate replacement of the aortic valve and the ascending aorta, provided that the sinuses of Valsalva and the coronary artery ostia remain intact. Accordingly, the Endo-Wheat technique is based on the same principle but is executed via a minimally invasive route. The core of the procedure consists of implanting a specialized covered stent-graft (TEVAR) into the ascending aorta to completely seal the primary intimal entry tear, restore perfusion to the true lumen, and simultaneously preserve the anatomical integrity of the aortic root, sinuses, and native coronary arteries.<\/p>\n
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The success of the endovascular approach in type A dissection primarily depends on the correct selection of anatomical landing zones for fixation and sealing. Ideally, the proximal landing zone should be located at the level of the sinotubular junction (STJ), above high-origin coronary ostia. If the dissection line or intramural hematoma extends close to the sinotubular zone, the use of classic straight stent-grafts becomes impossible due to the high risk of coronary occlusion. In such anatomically challenging conditions, the minimally invasive approach often requires an external wrapping of the distal aorta via mini-sternotomy or hybrid debranching to prepare a landing zone of adequate length and stability for the stent\u2014a modification known in medicine as “Zone 0” modification.<\/p>\n
From an innovative standpoint, the Endo-Wheat procedure is viewed as a transitional step between isolated stenting of the ascending aorta and the full Endo-Bentall concept. In cases where the patient presents with an isolated intramural hematoma, penetrating ulcer, or localized dissection of the ascending aorta without involvement of the aortic valve and sinuses, Endo-Wheat provides a reliable clinical solution. It circumvents the need for a transcatheter aortic valve replacement (TAVR) component, making the procedure technically less aggressive than a full Endo-Bentall conduit, which requires simultaneous endovascular replacement of the valve, root, and ascending aorta.<\/p>\n
Despite clear advantages\u2014such as reduced perioperative trauma, minimized blood loss, and a shorter postoperative rehabilitation period\u2014the Endo-Wheat methodology still faces significant challenges. The ascending aorta is characterized by high hemodynamic stress, constant exposure to radial forces, and sharp motion associated with the cardiac cycle. These factors increase the risk of stent-graft migration, endoleaks, and stent-graft-induced new entries (SINE). Furthermore, since specialized endoprostheses designed specifically for the ascending aorta are still in clinical trial and modification phases, surgeons often must resort to the off-label use of stents intended for the descending thoracic aorta.<\/p>\n
In clinical practice, decision-making during acute type A dissection is carried out by a multidisciplinary Heart Team based on individual patient risk factors and computed tomography angiography (CTA) data. For patients who meet the anatomical criteria but have absolute contraindications to open surgery, the Endo-Wheat procedure offers a life-saving alternative\u2014either as a definitive therapy or as a “bridging therapy” to achieve hemodynamic stabilization prior to subsequent staged surgical treatment. Along with technological progress and the development of specialized grafts, endovascular architecture of the ascending aorta is gaining an increasingly established position in modern interventional cardiac surgery.<\/p>\n