Complications and Management of the Thoracic Endovascular Aortic Repair

Abstract

Endovascular treatment in thoracic aortic diseases has increased in use exponentially since Dake and colleagues first described the use of a home-made transluminal endovascular graft on 13 patients with descending thoracic aortic aneurysm at Stanford University in the early 1990s. Thoracic endovascular aneurysm repair (TEVAR) was initially developed for therapy in patients deemed unfit for open surgery. Innovations in endograft engineering design and popularization of endovascular techniques have transformed TEVAR to the predominant treatment choice in elective thoracic aortic repair. The number of TEVARs performed in the United States increased by 600% from 1998 to 2007, while the total number of thoracic aortic repairs increased by 60%. As larger multicenter trials and meta-analysis studies in the 2000s demonstrate the significant decrease in perioperative morbidity and mortality of TEVAR over open repair, TEVAR became incorporated into standard guidelines. The 2010 American consensus guidelines recommend TEVAR to be “strongly considered” when feasible for patients with degenerative or traumatic aneurysms of the descending thoracic aorta exceeding 5.5 cm, saccular aneurysms, or postoperative pseudoaneurysms. Nowadays, TEVAR is the predominant treatment for degenerative and traumatic descending thoracic aortic aneurysm repair. Although TEVAR has been shown to have decreased early morbidity and mortality compared with open surgical repair, endovascular manipulation of a diseased aorta with endovascular devices continues to have significant risks. Despite continued advancement in endovascular technique and devices since the first prospective trial examined the complications associated with TEVAR, common complications, two decades later, still include stroke, spinal cord ischemia, device failure, unintentional great vessel coverage, access site complications, and renal injury. In this article, we review common TEVAR complications with some corresponding radiographic imaging and their management.

Early Diagnosis and Treatment of Nine Patients with Severe Multiple Injuries Accompanied by Traumatic Aortic Dissection during Emergency Treatment

“…Subsequently, accumulating evidence confirmed the effectiveness and acceptance of this approach [ 9 ]. Endovascular covered stenting is also associated with long-term complications, such as endoleaks, graft failure, technical failure, iliac vessel injury, and embolism of collateral vessels [ 9 – 11 ]. The use of aortic covered stents in subclavian artery branches can be effective in reducing complications of subclavian artery occlusion and stenosis.…”

Impact of ethnicity and race on outcomes after thoracic endovascular aortic repair

“…Ever since its first description in 1994 by Dake et al, thoracic endovascular aortic repair (TEVAR) has become the standard of care for the treatment of various pathologies involving the descending thoracic aorta (DTA), including aneurysm, acute dissection, intramural hematoma, and aortic rupture 1,2 . Aided by technological advances and increasing operator familiarity with endovascular approaches, TEVAR has been associated with improved short‐term outcomes compared to open surgical repair, including operative mortality, spinal cord ischemia, acute kidney injury, and cardiac and pulmonary complications 3,4 …”

Postoperative Intensive Care Management of Aortic Repair

“…With endovascular repair, the incidence of cardiac complications is significantly reduced (14.6% vs. 32.1%; OR 0.37 (0.20–0.66), p 0.001) [ 16 ]. Among early vascular complications, vascular access injuries are the most frequent (15–20%) together with lower limb ischemia [ 15 , 17 ]. The use of large delivery catheters, inserted in a retrograde manner via the iliofemoral vessels, can cause arterial dissection, arterial perforation or iliac artery rupture; retrograde arterial dissection can cause mesenteric or renal ischemia and iliac artery laceration or rupture results in retroperitoneal hematoma or hemorrhage [ 17 ].…”

“…Among early vascular complications, vascular access injuries are the most frequent (15–20%) together with lower limb ischemia [ 15 , 17 ]. The use of large delivery catheters, inserted in a retrograde manner via the iliofemoral vessels, can cause arterial dissection, arterial perforation or iliac artery rupture; retrograde arterial dissection can cause mesenteric or renal ischemia and iliac artery laceration or rupture results in retroperitoneal hematoma or hemorrhage [ 17 ]. Stent graft migration, endoleaks with aneurysm expansion and rupture, stent graft infection and erosion into the esophagus are the most frequent late complications.…”