Complications and Perioperative Management of Patients Undergoing Thoracic Endovascular Aortic Repair

Abstract

Endovascular treatments have become increasingly common for patients with a variety of thoracic aortic pathologies. Although considered less invasive than traditional open surgical approaches, they are nonetheless complex procedures. Patients undergo manipulation of an often calcified aorta near the origin of the carotid and subclavian vessels and have stents placed in a curved vessel adjacent to a perpetually beating heart. These stents can obstruct blood flow to the spinal cord, induce an inflammatory response, and in rare cases erode into the adjacent trachea or esophagus. Renal complications range from contrast-induced nephropathy to hypotension and ischemia to dissection. Emboli can lead to strokes and mesenteric ischemia. These patients have complex medical histories, and skilled perioperative management is critical to achieving the best clinical outcomes. Here, we review the medical management of the most common complications in these patients including stroke, spinal cord ischemia, renal injury, retrograde dissections, aortoesophageal and aortobronchial fistulas, postimplantation syndrome, mesenteric ischemia, and endograft failure.

Complications and Management of the Thoracic Endovascular Aortic Repair

“… 1 It is therefore crucial for clinicians to be familiar to the indications, procedure, and devices, a wide range of complications, and the management of potential complications. 12 …”

“…When the FDA approved the use of endovascular grafts for thoracic aortic diseases in 2005, it was limited to repairs of descending thoracic aneurysms, intramural hematoma, and penetrating atherosclerotic ulcer. 9 12 As TEVAR trials and outcomes studies demonstrated the safety of the procedure and decreased mortality and morbidity compared with open thoracic aortic repair, more patients became candidates for the procedure. 2 6 In 2012, FDA expanded graft use on traumatic aortic transection, and then in 2013 for all lesions of the descending thoracic aorta, including Type B dissections.…”

“… 2 6 In 2012, FDA expanded graft use on traumatic aortic transection, and then in 2013 for all lesions of the descending thoracic aorta, including Type B dissections. 12 …”

“…Despite significant advancement in endovascular techniques and device designs, there are certain TEVAR limitations due to patient anatomy and comorbidities. 12 While patients with advanced age and multiple comorbidities should undergo standard preoperative clearance, patients who have significant anatomic challenges require further considerations to prevent complications.…”

“…A landing zone typically requires a minimum of 20 mm of healthy aortic wall, proximally and distally. 9 10 12 The landing zone inner wall diameter is ideally between 16 and 42 mm, based on the current available device dimensions, and it is recommended to use 10 to 20% oversized grafts to ensure a complete seal and to prevent retrograde aortic dissection. 10 Insufficient proximal landing zone remains challenging for short proximal neck or significant angulation of the aortic arch near the take-off of the left subclavian artery (LSA).…”