MRI is significantly superior to biphasic CT for endoleak detection and rating of endoleak size, followed by uniphasic late and uniphasic arterial CT scans. MRI shows a significant number of endoleaks in cases with negative CT findings and may help illuminate the phenomenon of endotension. Endoleak rates reported after endovascular aneurysm repair substantially depend on the imaging techniques used.

Conclusion: There is a low incidence of neurologic morbidity and a relatively low mortality rate following descending thoracic aortic aneurysm repair when distal aortic perfusion and cerebrospinal fluid drainage are routinely utilized. Summary: The authors sought to document their rate of neurologic deficit and mortality following thoracic aneurysm repair with routine utilization of distal aortic perfusion and cerebrospinal fluid drainage. There were 355 descending thoracic aortic aneurysms repaired at the author's institution between February 1991 and September 2004. Twenty nine patients were excluded from analysis because of involvement of the aortic arch and 26 patients with rupture were also excluded. There were therefore 300 patients analyzed for outcomes. Of these, 198 (66%) were men and 102 (35%) were women. Mean age was 67 years. A combination of distal aortic perfusion and cerebrospinal fluid drainage was utilized in 238 patients. There were 62 patients who underwent simple cross-clamp without utilization of distal aortic perfusion or CSF drainage. There was a 2.3% incidence of neurologic deficit in this series (7 of 300 patients). The rate of neurologic deficits in the patients treated with cerebrospinal fluid drainage and distal aortic perfusion was 1.3% (3 of 238 patients). The rate of neurologic deficit in patients not treated with cerebrospinal fluid drainage and distal aortic perfusion was 6.5% (4 of 62 patients; P Ͻ 0.02). Neurologic deficits in both groups were only seen when the aneurysm involved the entire descending thoracic aorta. Predictors of neurologic deficit included use of cerebrospinal fluid drainage and distal aortic perfusion (odds ratio [OR] 0.19; P ϭ 0.02), previous repaired abdominal aortic aneurysm (OR, 7.0; P ϭ 0.005) and aneurysm that involved the entire descending thoracic aorta (OR 13.73; P ϭ 0.02) and a history of cerebrovascular disease (OR 4.7; P Ͻ 0.03). Thirty-day operative mortality was 8%. Predictors of 30 day mortality were preoperative renal dysfunction (OR, 4.6; P Ͻ 0.01) and female sex (OR, 2.9; P Ͻ 0.03). Comment: This paper from Dr. Safi's group in Houston indicates what is possible to achieve with open thoracic aneurysm repair. I doubt this volume of patients and this level of expertise is present in many institutions. Because of this, papers such as this cannot really be used to justify or not justify endovascular techniques of thoracic aneurysm repair. However, with data such as this it would seem silly not to provide, when possible, CSF drainage and distal aortic perfusion in patients undergoing open descending thoracic aortic aneurysm repair.

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