Endovascular Repair of the Descending Thoracic Aorta: Evidence for the Change in Clinical Practice

Abstract

The purpose was to review outcome data following endovascular repair of the descending thoracic aorta from reports published between 1994 and 2004. To accomplish this task, 1,518 patients underwent endovascular repair for thoracic aortic disease; 810 thoracic aortic aneurysms, 500 type B thoracic aortic dissections, and 106 traumatic ruptures. The 30-day mortality rate was 5.5% and 6% for late postoperative deaths. The primary technical success rate was 97%, with only 15 patients requiring open conversion. Neurologic deficits occurred in 29 patients. In total, 118 endoleaks were reported; 29 were restented, and the remainder required surgical intervention. Graft infection occurred in 6 cases, and migrations were detected in 10. The conclusion reached is that endovascular repair of descending thoracic aortic disease is feasible and can be achieved with low rates of perioperative morbidity and mortality. As few long-term data exist on the durability of thoracic stent grafts, lifelong surveillance remains necessary.

Current Management of Traumatic Rupture of the Descending Thoracic Aorta

“…Their initial primary interest, and indeed the bulk of the literature since, was with atherosclerotic aneurysms. We now know that endografting is an attractive option that can avoid the morbidity of a thoracotomy in patients with multiple injuries, and that it appears to reduce the risk of paralysis [10-15]. As with all invasive procedures, there are specific complications and anatomic considerations that need to be incorporated into the planning of endovascular treatments of traumatic thoracic injuries.…”

The Endovascular Approach to Acute Aortic Trauma

“…Aortobronchial and/or aortoesophageal fistula have been reported years after endografting [17,75] . Sayed and colleagues reviewed 1518 cases reported in the literature of thoracic endografting (primarily for non-traumatic thoracic aneurysmal disease) and found 6 cases (0.4%) of thoracic graft infection, paralleling the experience with abdominal grafts [21,76] . The primary risk factors were other intravascular sources of infection.…”

“…We now know that endografting is an attractive option that can avoid the morbidity of a thoracotomy in patients with multiple injuries, and that it appears to reduce the risk of paralysis [14][15][16][17][18] . Some centers have seen dramatic improvements in outcome using the endovascular approach [19][20][21] . In North America, currently 2/3 of blunt aortic injury are managed endovascularly [22] .…”

Endovascular Approaches and Perioperative Considerations in Acute Aortic Dissection

“…Aortic dissection has broadly been categorized into those involving the ascending aorta (Stanford A or Debakey Seminars in Cardiothoracic and Vascular Anesthesia 15 (4) types I and II) and isolated descending aorta with or without distal extension (Stanford B or Debakey type III). Type A dissections represent a surgical emergency requiring surgical replacement of a portion of the ascending aorta in almost all cases.…”

“…Thoracic endovascular aortic repair (TEVAR) has emerged as a preferred treatment for these patients when coverage of the entry tear and safe device delivery are possible. 4 Most thoracic endografts require access vessels of 8 to 9 mm in size for delivery. Common femoral arteries are preferred, but other sites such as the common iliacs or the abdominal aorta can be used with surgical conduits (Figure 1).…”