Endovascular stent grafting of descending thoracic aortic aneurysms

The Long-Term Clinical Impact of Thoracic Endovascular Aortic Repair (TEVAR) for Advanced Esophageal Cancer Invading Aorta

Background

Advanced esophageal cancer invading the aorta is considered unsuitable for surgery with definitive chemotherapy or chemoradiation as the treatments of choice. In the current study, we evaluated the long-term clinical impact of combining thoracic endovascular aortic repair (TEVAR) with multimodality treatment in caring for such patients.

Methods

We evaluated 48 patients who had advanced esophageal cancer with aortic invasion. The oncological outcome, including overall survival (OS) and progression-free survival (PFS), after multimodality treatment with or without TEVAR is evaluated for these patients.

Results

Overall, 25/48 patients (52.1%) received a TEVAR procedure. There was no significant difference in OS (p = 0.223) between patients who did or did not receive TEVAR; however, patients who received TEVAR had significantly less local tumor recurrence (p = 0.020) and longer PFS (p = 0.019). This impact was most evident in patients who received both TEVAR and esophagectomy, with an incremental increase in hazard ratio (HR) for disease progression of 2.89 (95% confidence interval [CI] 0.86–9.96) and 4.37 (95% CI 1.33–14.33) observed under multivariable analysis, respectively, in comparison with patients who underwent only one or neither of these procedures (p = 0.005 for trend test).

Conclusion

TEVAR is a feasible procedure for esophageal cancers invading the aorta and can be used for curative-intent resection to improve local tumor control and PFS.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-10081-3.

Result of Thoracic Endovascular Aortic Repair for Patients with Esophageal Cancer

BACKGROUND

Bleeding from the thoracic aorta is potentially fatal in patients with advanced esophageal cancer. Thoracic endovascular aortic repair (TEVAR) was recently applied for aortic invasion by esophageal cancer. However, only a few case reports have been published. This study was performed to clarify the effectiveness and safety of TEVAR for patients with advanced esophageal cancer.

METHODS

We retrospectively reviewed 18 patients who underwent TEVAR for esophageal cancer. We also performed a literature search and reviewed 21 similar cases.

RESULTS

From 2007 to 2016, 10 patients were treated on an emergent basis for aortic hemorrhage (salvage group) and 8 patients underwent urgent prophylactic surgery (prophylactic group). Hemostasis was achieved in all cases. One (10%) patient in the salvage group died of aspiration pneumonia on postoperative day 1, while all patients in the prophylactic group survived for >1 month. The median survival period in the salvage and prophylactic group was 3.25 and 11.10 months, respectively. The longest survivor was still alive 9 years after TEVAR and chemoradiotherapy. No fatal adverse events or negative impacts on subsequent treatment for esophageal cancer occurred.

CONCLUSIONS

TEVAR is feasible, safe, and effective in preventing fatal aortic hemorrhage secondary to esophageal cancer invasion, although it is palliative in most cases. Because the outcomes of emergent TEVAR after bleeding tended to be worse in the salvage than in prophylactic group, prophylactic TEVAR may be considered a viable treatment option for patients with aortic invasion by advanced esophageal cancer.

Stent Grafts for Thoracic Aortic Pathology: Single-Center Experience in Western Australia

The purpose of this article is to report a single-center experience in treating thoracic aortic pathology with stent grafts. This is a retrospective review of cases done within a period of 30 months.

Between January 2002 and May 2004, 12 patients were treated in our institution with thoracic stent grafts ( n = 12) for various clinical conditions. There were seven men and five women. Three patients required emergency treatment ( n = 3), two for aortic transection and one for iatrogenic injury during lung biopsy. Others were treated electively ( n = 9).

All patients were high risk for open surgery. There was one perioperative death, with a patient with multiple trauma succumbing to head injury 4 weeks after stent graft insertion. There was no incidence of paraplegia. Three patients underwent bypass surgery in the neck to achieve an adequate proximal seal zone prior to stent grafting. One patient with an aneurysm of the descending thoracic aorta required an extension limb below the original graft for an increase in sac size, possibly owing to endotension. Renal failure occurred in one patient and resolved without dialysis. One patient died 18 months after her procedure, possibly owing to aneurysm expansion.

Stent grafts are a viable alternative to open surgery for thoracic aortic pathology in high-risk individuals. Visceral and spinal cord ischemia is less prevalent with stent grafts compared with open surgery. The short-term results are promising. Long-term follow-up is awaited. Stent grafts might have greater impact in the thoracic aorta than the abdominal aorta for which they were initially developed.

Early experience of thoracic endovascular aortic repair: a local single hospital experience

Purpose

The purpose of this retrospective study was to evaluate the short- to mid-term results of thoracic endovascular aortic repair (TEVAR) in Wonkwang University School of Medicine & Hospital.

Methods

Between February 2009 and May 2011, 8 consecutive patients had undergone endovascular stent-grafting for thoracic aortic diseases. Five patients were treated for traumatic thoracic aortic injuries, two patients were treated for thoracic aneurysms and one patient was treated for a pseudoaneurysm due to penetrating aortic ulcers. Attempted stent-graft deployment was performed electively in 6 patients and emergently in 2. Follow-up was performed at 1-month, 6-month, 1-year, and annually thereafter.

Results

Technical success rates were achieved in 87.5% and the 30-day mortality rate was 0%. Mean hospital length of stay after TEVAR was 30 days in traumatic thoracic aortic injuries and 10 days in thoracic aneurismal diseases. Intra-operative Type I endoleak due to migration at deflation was visualized in 1 patient, which was treated by insertion of another stent-graft. During follow-up, a major complication was encountered in one patient who received carotid-subclavian bypass to relieve left arm ischemia. After 5 months he was treated with arch replacement for aortic arch aneurysm with type I endoleak at proximal site after endovascular treatment. The 30-day mortality rate was 0%. However, 1 case of mortality (12.5%) was observed during the follow-up period.

Conclusion

The short and mid-term results of endovascular repair of thoracic aortic diseases are promising. TEVAR is an effective procedure in the management of thoracic aortic diseases.

Thoracic Endovascular Aortic Repair: A Local Single Institution Experience

Introduction: The purpose of this retrospective study was to evaluate the short- to mid-term results of the endovascular repair of thoracic aortic disease and to present an overview of our experience with thoracic endovascular aortic repair (TEVAR) in our institution. Materials and Methods: A retrospective review of all patients who were treated and underwent TEVAR in our institution between August 2004 and November 2009 was conducted. Results: Technical success was achieved in 100% of the patients and the 30-day mortality rate was 0%. Perioperative endoleak was visualised at the end of the procedure in 4 patients. Secondary endoleak was observed in 2 patients. Mean hospital length of stay post-TEVAR was 15.4 days. Postoperative major complications were observed in 4 patients. The 30-day mortality rate was 0%, with 2 mortalities (11.1%) during the follow-up period. Conclusion: This study adds to the growing body of literature that support TEVAR as an effective procedure in the management of thoracic aortic diseases and reflects its feasibility in our population. Further technical advancement in stent grafts, careful selection of patients and standardised peri-procedural care would contribute to further improvements in clinical outcomes. Key words: Endovascular, Stent graft, TEVAR, Thoracic aneurysm, Thoracic dissection

Endovascular interventions for descending thoracic aortic aneurysms: The pivotal role of the clinical nurse in postoperative care

Descending thoracic aortic aneurysms (dTAA) comprise 40% of all aneurysms arising from the thoracic aorta. Because rupture of thoracic aneurysms is associated with a 94% mortality rate, timely detection, surveillance and treatment is imperative. Endovascular stent-graft repair of thoracic aneurysms was first performed in 1992 and has become an accepted treatment option for this condition in select candidates. There is an abundance of information for the care of patients after open surgical repair of dTAA. However, still relatively few written guidelines exist in the nursing literature for postoperative care and complications associated with endovascular stent-graft repair. The prevalence of aortic endografting, however, now makes it necessary for nurses to have a solid knowledge base in the operative procedure, complications and postoperative care for this patient population. Ideal candidates for aortic endografting undergo CTA or MRI preoperatively and fit a set of strict anatomic criteria to ensure proper delivery and fixation of the device. The early postoperative care focuses on minimizing pulmonary complications, paraplegia, renal failure and embolic complications such as stroke and limb ischemia through skilled nursing assessment and interventions. Late complications such as stent-graft migration, kinking, stent fracture and endoleak are often without symptoms, making it necessary for patients to be educated about these potential complications and to be encouraged to comply with lifelong follow up. This overview provides a sound cognitive framework for nurses practicing in a vascular surgery milieu.

A case of paraplegia following endovascular stent repair of descending thoracic aortic aneurysm

Paraplegia secondary to spinal cord infarction is a recognized complication of open thoracic and thoracoabdominal aortic aneurysm (TAA) repair. TAA is serious and unpredictable condition. Therefore, aortic repair requires thorough information on managing the potential complications will facilitate improve control the problem. We report the symptoms and management of paraplegia in a patient who underwent stent insertion as TAA.

Delivery of antegrade cerebral perfusion during descending aortic reconstruction: a case report

Antegrade cerebral perfusion (ACP) has been demonstrated to be a safe and effective method of providing adequate protection to the brain during hypothermic circulatory arrest. By improving oxygen delivery to the cerebral capillaries, users of this technique have reported fewer temporary neurological deficits in postoperative periods, even after prolonged periods of circulatory arrest. Furthermore, ACP may be delivered with little alteration to the cardiopulmonary bypass (CPB) circuit. Surgical correction of a descending aortic aneurysm can provide a challenge when the left subclavian artery is involved. A period of hypothermic circulatory arrest is required to complete the proximal anastamosis of the graft. Access to the cerebral vessels for selective cerebral perfusion is limited during a left thoracotomy approach. A 54-year-old female presented with a computerized tomography (CT) scan of a descending aortic aneurysm, originating at the base of the left subclavian artery. Surgical intervention using CPB via femoral-femoral cannulation was employed. The patient was systemically cooled to 22 degrees C. Selective antegrade cerebral perfusion was administered via cannulation of the left common carotid artery. Antegrade cerebral perfusion lasted 19 minutes, with improved transcranial oximetry readings. The patient was successfully weaned from CPB. The patient was discharged on postoperative day nine with no evident suquelae. It is believed that the application of ACP in this procedure further improved patient outcome.

Pathophysiology, diagnosis, and management of aortic dissection

Aortic dissection is an uncommon but potentially fatal disease with catastrophic complications. A high level of suspicion is required for successful diagnosis as presenting symptoms are so variable that dissection may be overlooked in up to 39% of cases. It most commonly presents in the elderly population with a history of chronic hypertension. Rapid intervention is necessary as delay leads to higher mortality. Despite advances in diagnostic and therapeutic techniques, morbidity and mortality remains high. Advances in diagnostic imaging have raised the awareness of variants of aortic dissection, including intramural hemorrhage and penetrating aortic ulcer. This distinction is important as the clinical course of these variants differs from that of classical aortic dissection, and thus treatment may also differ. Understanding of these variants has also led to the recognition of markers that may help predict progression to classical aortic dissection and thus warrant closer vigilance in selected patient populations. The recognition that rapid diagnosis is required for management of aortic dissection has led to the investigation of serum tests as diagnostic aids. Serum smooth muscle myosin heavy chain, d-dimer, and serum soluble elastin fragments are promising tests that may help raise suspicion for the diagnosis of acute aortic dissection. The high mortality associated with surgical therapy has led to investigation of alternative approaches. Endovascular therapy has emerged as a viable option in patients with type B dissection who are too unstable for surgery. However, long-term follow up is required to validate this procedure.

Thoracic aortic stent-graft devices: problems, failure modes, and applicability

Optimal treatment strategies for pathologies of the descending thoracic aorta are still controversial. Open surgery is complex, while endovascular devices allow nonsurgical access to the thoracic aorta. Endografts can be inserted via a peripheral artery while maintaining aortic blood flow without any need for clamping. Both short- and mid-term outcomes after endografting thoracic aneurysm and type B aortic dissection are encouraging, with significantly lower morbidity and early mortality compared with open surgery. However, despite emerging popularity and growing interest as an alternative to surgery, endograft design and manufacturing have not kept pace with growing clinical ambition. Major challenges associated with endovascular procedures using the current generation of endografts range from the relative rigidity and size of the delivery system to the failure of thoracic endografts to conform snugly to the anatomy of the aortic arch. Nonconformity of grafts may lead to graft instability, endoleak, and procedural failure. Current delivery systems are potentially traumatizing and, at times, too inflexible to track through tortuous, calcified vessels, and often require surgical exposure of the access vessel. Although efforts have been made by the industry to improve conformability and fixation in the aortic arch, given the spiraling movement of the thoracic aorta with each ventricular contraction, much work needs to be done on miniaturization and creation of disease-specific devices. The aim of this work is to give an overview on thoracic aortic stent-graft devices with focus on problems, failure modes and potential improvements.

Incidental finding of lung cancer in a patient with thoracic aortic aneurysm ? simultaneous management. A case report

The simultaneous existence of thoracic aortic aneurysm and lung cancer is a rare finding, especially if the malignancy is primary and does not involve the aortic wall. In this report, we present a case of a typical descending thoracic aneurysm combined with a primary adenocarcinoma of the left lower lobe. The aneurysm was repaired with a Dacron graft without use of extra corporeal circulation and a typical left lower lobectomy was performed. In such cases, aneurysms should be treated primarily with endovascular stents. However, if this is not possible, a combined operation can be performed with good outcome.

Secondary Interventions after Elective Endovascular Repair of Degenerative Thoracic Aortic Aneurysms: Results of the European Collaborators Registry (EUROSTAR)

PURPOSE

The need for secondary interventions is an important indicator of intermediate and long-term success of endovascular repair of degenerative thoracic aortic aneurysm. The purpose of this study was to analyze the occurrence and consequences of secondary procedures.

MATERIALS AND METHODS

Data from 213 patients electively subject to operation for degenerative thoracic aortic aneurysm and achieving primary success and who were enrolled in the EUROSTAR registry were analyzed. Secondary procedures were categorized as follows: transfemoral endovascular reintervention, extraanatomic secondary procedures, and transthoracic surgery.

RESULTS

Overall, 25 (12%) of the patients with an elective treatment for a degenerative thoracic aneurysm had secondary intervention, occurring at a mean of 8 months after the initial procedure. Seventeen (68%) of the secondary interventions were via a transfemoral approach, six (24%) involved a transthoracic procedure, and two (8%) involved extraanatomic bypass. The cumulative percentage of freedom from intervention at 1 and 2 years was 86% and 83%, respectively. Endoleak (relative risk, 5.21) was the most frequent cause for secondary transfemoral intervention. For the other secondary interventions, no principal indication for reintervention could be identified. Patients who needed secondary interventions more frequently suffered from preoperative back pain (20% vs 44%, P = .008), and their thoracic aneurysms had a longer length (mean, 95.6 mm vs 133.2 mm, P = .006). The 2-year cumulative survival rate of patients without secondary intervention was 85% compared with 58% in the patients who received secondary intervention (P = .0001).

CONCLUSIONS

Regular surveillance after endovascular degenerative thoracic aneurysm repair is needed as secondary interventions were required throughout the follow-up period.

Recurrent aortic aneurysms following thoracic aortic stent-graft repair in a patient with Cogan syndrome

PURPOSE

To report the need for multiple surgical interventions to treat recurrent aortic aneurysms in a patient with Cogan syndrome.

CASE REPORT

A 17-year-old Chinese man with clinical Marfanoid features had a left common carotid artery pseudoaneurysm electively repaired with an autologous saphenous vein graft. Four months later, he presented with acute chest pain. Computed tomography (CT) revealed a 1-cm pseudoaneurysm at the mid descending aorta; a 24 x 100-mm Talent stent-graft was implanted to exclude the pseudoaneurysm. He was also found to have increasing left-sided hearing loss. A month later, the patient was re-admitted with vertigo and keratitis, which were treated appropriately. Nine months following stent-graft insertion, he was admitted with acute hemoptysis. Urgent CT showed a rupture at the proximal end of the stent-graft, with hemorrhage into the lung parenchyma. In an emergent procedure, the stent-graft was removed, and the descending thoracic aorta was repaired. Intraoperatively, a large pseudoaneurysm was found arising from the proximal part of the stented aorta, which appeared thickened. His postoperative recovery was uneventful. Nine months after the thoracotomy, a routine CT revealed an aneurysm at the distal descending thoracic aorta. On re-thoracotomy, a de novo saccular aneurysm was found 2.5 cm from the distal anastomosis. The affected segment was replaced with a Dacron graft. The distal aorta appeared thickened and edematous; histology confirmed aortitis. The patient was subsequently diagnosed with Cogan syndrome and given corticosteroids and methotrexate. There is no evidence of recurrence at nearly 2 years after the last intervention.

CONCLUSION

This case highlights the pitfalls of stent-graft repair in a patient with presumed connective tissue disease.

Acute aortic syndrome: pathology and therapeutic strategies

Acute aortic syndrome (AAS) describes the acute presentation of patients with characteristic "aortic pain" caused by one of several life threatening thoracic aortic pathologies. These include aortic dissection, intramural haematoma, penetrating atherosclerotic ulcer, aneurysmal leak, and traumatic transection. AAS heralds imminent aortic rupture. Highlighting acute aortic pathology as an AAS is therefore important to encourage prompt recognition of this condition and avoid diagnostic delays. The management of AAS remains a therapeutic challenge. The traditional surgical approach to acute "type B" (descending thoracic) aortic pathology is unsatisfactory with high morbidity and mortality. Endovascular aortic stent grafts now represent an alternative minimally invasive approach in these patients who are often poor surgical candidates. Studies show endovascular repair to be technically feasible with fewer complications. This review discusses AAS pathology and in particular assesses the current role for endovascular aortic repair in its treatment.

Thoracoabdominal aortic aneurysm: diagnosis and management

Thoracoabdominal aortic aneurysm is defined as a focal and localized dilatation of the aorta 1.5 to 2 times the diameter of the normal adjacent aorta and containing all three layers of the arterial wall. Conventional open surgical repair remains the gold standard for the majority of the patients with thoracoabdominal aortic aneurysm. Endovascular stent-graft aortic repair is a promising emerging therapy, which at present is considered an alternative to surgery in the elderly and in those with significant comorbid conditions. Adjunctive beta-blocker therapy should be used in all patients to reduce the shear force on the aortic wall.

Endovascular Stent Grafting of Thoracic Aortic Aneurysms

The use of endovascular stent grafts is a leading technological advancement in the treatment of thoracic aortic aneurysms, and is being trialed in the United States as an alternative to medical management and traditional surgical repair. Aortic stent grafts, initially used only for abdominal aortic aneurysms, have been used for over 10 years in Europe and are currently under United States Food and Drug Administration investigation for the treatment of chronic and acute aortic aneurysms. Diseases of the thoracic aorta are often present in high-risk individuals, and, as a result, there is a high morbidity and mortality rate associated with both medical and surgical management of these patients. The development and refinement of endovascular approaches have the potential to decrease the need for traditional surgical repair, especially in high-risk populations such as the elderly and those with multiple comorbidities. Endovascular technology for thoracic repair has only been used in Europe for the last 10 years, with no long-term outcomes available; however, preliminary research demonstrates favorable early and midterm outcomes showing that endovascular stent graft placement to exclude the dilated, dissected, or ruptured aorta is both technically feasible and safe for patients. The article highlights the historical perspective of endovascular stent grafting as well as a description of patient selection, the operative procedure, benefits, risks, and unresolved issues pertaining to the procedure. A brief review of aneurysm and dissection pathophysiology and management is provided, as well as postoperative management for acute care nurses and recommendations for clinical practice.

Endovascular Stent-Graft Treatment of Thoracic Aortic Disease

Aneurysmal diseases of the thoracic aorta are life-threatening conditions. In such cases, stent-graft treatment has been proposed as an alternative to surgery. The morbidity and mortality associated with endovascular repair are significantly lower than those associated with open surgery. In the largest surgical series, the mortality ranged from 5% to 20%. In studies of endovascular repair, the 30-day mortality was 0%-20% and the periprocedural stroke rate was 0%-7%. Often, open surgery is prohibited in patients with these high-risk lesions; thus, in many cases endovascular treatment is the only alternative. Thoracic aortic diseases that can be treated with endovascular stent-graft placement include aneurysms, dissection, traumatic rupture, traumatic pseudoaneurysms, intramural hematoma, penetrating atherosclerotic ulcers, and aortic rupture. Thorough preprocedure imaging is essential for selecting patients, choosing the stent-graft devices, and planning the intervention. Prerequisites for endovascular stent-graft placement are an adequate neck for graft attachment and adequate vascular access. When the ascending aorta or aortic arch is involved, surgical and endovascular procedures can be combined and performed simultaneously, allowing treatment of a wider range of cases. An experienced interdisciplinary team is needed to manage such cases.

Replacement of the Descending Aorta using the daVinci Surgical System in a Sheep Model: Comparison of Anastomosis Techniques

OBJECTIVE

The purpose of our study was to assess the feasibility of a closed-chest replacement of the descending thoracic aorta utilizing the daVinci surgical robotic system and to compare hand-sewn running anastomosis to interrupted nitinol clips (Coalescent Surgical).

METHODS

Six sheep underwent replacement of the descending aorta using Intuitive's daVinci surgical system. Using the daVinci, the descending aorta was dissected out and individual intercostal arteries were clipped and divided. Following systemic heparinization, the aorta was occluded using percutaneous vascular clamps (Chitwood clamps). The descending aorta was excised and replaced with a woven graft. The proximal and distal anastomoses were varied in each animal between a running 4-0 polypropylene technique and interrupted nitinol clips. Anastomoses were inspected for hemostasis and tested for burst strength.

RESULTS

Five of six animals survived the procedure. The average procedure time was 93 minutes. Cross-clamp times range from 55 to 25 minutes (average of 37 minutes). There was no significant difference in time between U-clip anastomoses (17 +/- 4.8 minutes) and sutured anastomoses (10.6 +/- 3.1 minutes). The burst pressure was higher for sutured anastomosis than for U-clips (214.6 +/- 61 and 110 +/- 35, respectively).

CONCLUSION

Replacement of the descending aorta with a graft is feasible in a closed chest model utilizing Intuitive's daVinci surgical system. While mean burst strengths were higher with a running sutured anastomosis, there was no difference in anastomotic time or ultimate hemostasis between techniques.

Single Center Experience with a New Commercially Available Thoracic Endovascular Graft

PURPOSE

To evaluate the intra-operative performance and clinical outcome of a new commercially available stent-graft for the treatment of thoracic aortic diseases.

METHODS AND PATIENTS

From January 2003 to October 2004, 45 consecutive patients received endovascular treatment with the Zenith TX1 device for diseases of the thoracic aorta at a single center in northern Italy. Indications included disease of the descending thoracic aorta in 26 cases, of the aortic arch in 17 cases and of the thoraco-abdominal aorta in two cases. We treated 38 atherosclerotic aneurysms, two post-traumatic aortic ruptures, two penetrating ulcers, two chronic dissections and one case was treated for aortic bleeding after voluntary acid ingestion for attempted suicide. General anesthesia was used in 20 cases. Combined or hybrid endovascular and open surgical repair was performed in 11 patients. Mean follow-up was 7 months (range 1-22 months).

RESULTS

Technical success was obtained in 44 patients (98%). One primary type I endoleak occurred (2%). ICU was used in 12 cases with a mean stay of 1 day. The mean hospital stay was 6 days (range 4-13 days). There were no hospital deaths or strokes but one transient paraplegia (2%). A type II endoleak was observed in one case and resolved spontaneously 1 month later. No aneurysm enlargement, endograft migration or structural failures were observed during follow-up. Two late unrelated-deaths were observed.

CONCLUSIONS

This stent-graft does not fulfill all the characteristics of the ideal graft, however, it proved to be safe and allowed satisfactory short term results in this group of patients treated at a single center.

Endovascular treatment of thoracic aortic diseases: Combined experience from the EUROSTAR and United Kingdom Thoracic Endograft registries

PURPOSE

The objective of this study was to assess the initial and 1-year outcome of endovascular treatment of thoracic aortic aneurysms and dissections collated in the European Collaborators on Stent Graft Techniques for Thoracic Aortic Aneurysm and Dissection Repair (EUROSTAR) and the United Kingdom Thoracic Endograft registries.

METHODS

Four hundred forty-three patients underwent endovascular repair of thoracic aortic disease between September 1997 and August 2003 (EUROSTAR, 340 patients; UK, 103 patients). Patients represented 4 major disease groups: degenerative aneurysm (n = 249), aortic dissection (n = 131), false anastomotic aneurysm (n = 13), and traumatic aortic injury (n = 50).

RESULTS

Mean age in the entire study group was 63 years. Fifty-two percent of patients were deemed at high risk for open surgery because of major comorbidity. Sixty percent of patients underwent an elective procedure, and 35% required emergency treatment. Conventional indications for treatment of aortic dissection, including aortic expansion, continuous pain, rupture, or symptoms of branch occlusion constituted the basis for endograft placement in 57% of patients, whereas in 43% of patients aortic dissections were asymptomatic. Primary technical success was obtained in 87% of patients with degenerative aneurysm and in 89% with aortic dissection. Paraplegia was a postoperative complication in 4.0% of patients with degenerative aneurysm and 0.8% of patients with aortic dissection (not significant). Thirty-day mortality in the entire study group was 9.3%, with mortality rates after elective procedures of 5.3% for degenerative aneurysms and 6.5% for aortic dissection. Mortality for degenerative aneurysm after emergency repair was higher (28%; P <.0001) then after elective procedures. For aortic dissection the emergency repair rate was 12% (not significant compared with elective repair of aortic dissection, and P = .025 compared with emergency repair of degenerative aneurysm). One-year follow-up was complete in 195 patients. The outcome at 1 year was more favorable for aortic dissection than for degenerative aneurysm with regard to aortic expansion (0% vs 15%; P = .001) and late survival (90% vs 80%; P = .048). In the groups with false anastomotic aneurysm and traumatic aortic injury, 30-day mortality rates were 8% and 6%, respectively.

CONCLUSION

This multicenter experience demonstrates acceptable rates for operative mortality and paraplegia after endovascular repair of thoracic aortic disease. Outcome after 30 days and 1 year was more favorable for aortic dissection than for degenerative aneurysm. However, the durability of this technique is currently unknown, and continued use of registries should provide data from long-term follow-up.

Endovascular Treatment of Thoracic Aortic Disease: Four Years of Experience

BACKGROUND

The aim of this retrospective study is to investigate efficacy and middle-term results of the stent graft treatment for diseases of descending thoracic aorta.

METHODS AND RESULTS

From March 1999 to October 2003, 132 patients (113 male and 19 female, mean age 62+/-14 years) were enrolled. They were divided into 4 groups: aneurysms (43, group A), post-traumatic lesions (24, group B), and complicated type B dissections (43, group C). Twenty-two further patients, with chronic type B dissection and not suitable for endovascular or surgical or hybrid techniques because of multiple entry tears without difference between the true and false lumen and poor clinical conditions, were obliged to receive medical management only (group D). All patients underwent computed tomography (CT) scan and angiography as preoperative assessment. An optimal deployment with exclusion of the aneurysm and/or closure of the entry tear in dissection was achieved in 96.4% (106/110) of the patients that were discharged in good conditions within 6 days. No spinal cord injuries were observed. The follow-up (average 20.82+/-10.01 months, range 1 to 55 months), performed with serial chest CT scans, was 100% complete. No stent graft-related complications were detected, although only in 1 case, an asymptomatic rupture of the Excluder connecting bar was found with a perforation of the fabric and an intra-aortic exposition of the bar itself. In 2 patients with chronic dissection an asymptomatic type II endoleak was detected. A total of 4 hospital deaths resulted in an overall operative mortality of 3.9%. Seven patients (6.3%) died during the follow-up 5 of them for other diseases (4.5%). However, a 40.9% mortality was observed within the obliged medical treatment group.

CONCLUSIONS

Endovascular treatment of thoracic aortic diseases, even in the acute phase, may represent a valid option with a low mortality rate. Moreover, the efficacy is proved in the middle-term whereas the long-term follow-up is still pending.