Endovascular Stent Graft Repair of Abdominal and Thoracic Aortic Aneurysms

Abstract

Stent graft therapy for aortic aneurysms is a valuable alternative to open aortic repair, especially in older sicker patients with large aneurysms. Continued device improvements coupled with an enhanced understanding of the important role of aortic pathology in determining therapeutic success will eventually permit ESGs to be a more durable treatment of aortic aneurysms.

Conventional Open Repair of Descending Thoracic Aortic Aneurysms

“…Amid the surge in development of endovascular stent grafts for thoracic aortic disease, there has been a bias in favor of endovascular treatments that has been thwarted by inappropriate comparisons of the results of open thoracoabdominal aortic replacements (ie, more extensive resections) to thoracic endovascular aortic repair (TEVAR) of more limited descending thoracic aortic aneurysms. The feasibility of TEVAR for descending thoracic aortic aneurysms is now firmly established, 26,27,45,57,[65][66][67][68][69]71,[107][108][109][110][111][112][113][114][115][116][117][118][119][120][121][122][123] but the indications for doing so have not been clearly defined. In part, the discrepancy between feasibility and indication rests with the lack of long-term followup data in favor of TEVAR and, consequently, a lack of understanding of the relative risk of TEVAR compared with medical management and conventional open replacement of descending thoracic aortic aneurysms.…”

Complex Thoracic Aortic Aneurysm: A Combined Open and Endovascular Approach

“…In recent series, mid-term results are promising without operative mortality (9-10) and a technical success rate of 85-100% (8)(9)(10).…”

“…Discussion remains with regard to the incidence, the clinical approach and management of some endoleaks (8)(9)(10). The reported incidence of early type II endoleaks is 10-14% (8,9) and of type I and III endoleaks is 11-15% (8,10). Consensus exists on the uniform dangers of untreated type I endoleaks (8).…”

“…The first series of 13 patients was published in 1994 (7). The primary goal of a less invasive endovascular approach is to reduce postoperative morbidity and mortality (8). There are three major conditions in order to place a thoracic endoprosthesis : a favourable localization and morphology of the aneurysm, a distal vascular access of sufficient size and a limited tortuosity of the abdominal and thoracic aorta.…”

“…Consensus exists on the uniform dangers of untreated type I endoleaks (8). Management of type II endoleaks remains controversial ; some sealed spontaneously (9), but sometimes reintervention is necessary, especially if the aneurysm is increasing (8).…”