Endovascular Stent-Graft Treatment of Thoracic Aortic Disease

Abstract

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.

Endovascular repair of thoracic and abdominal aortic ruptures: a single-center experience

“…CT angiography is widely recommended for assessing the feasibility of the endovascular procedure and for the measurement of vascular diameters when the patient is relatively stable and is able to tolerate CT examination (4,5). In our study we did not have to use additional stent-graft segments due to the exact sizing of the stent-grafts according to CT angiography measurements, except in one procedure in which an inadequate deployment occurred.…”

“…Despite significant improvements in critical care support, noninvasive diagnosis, anesthesia, and cardiosurgery over the last few decades, the conventional open surgical repair of an aortic rupture still carries a significant risk of serious complications and mortality (4)(5)(6). Perioperative mortality rates associated with the surgical repair of a ruptured abdominal aortic aneurysm (rAAA) or a thoracic aortic injury (TAI) ranges from 32% to 70% (5,(7)(8)(9).…”

“…Patients with rAAA and traumatic TAI are not frequently good surgical candidates because of old age, comorbidities, and concomitant multiple-system injuries, such as cranial injuries, multiple fractures, and pulmonary contusions. Surgical repair of the thoracic or abdominal aorta in patients with concomitant injuries and comorbidities is associated with high morbidity and mortality (4,10,11). Therefore, endovascular repair techniques have emerged as a promising alternative in these patients (12).…”

Banding Technique for Endovascular Repair of Arch Aneurysm With Unsuitable Proximal Landing Zone

“…The effectiveness of endovascular repair has been shown by several investigators; [1][2][3][4][5][6] however, aneurysms located at the aortic arch, which is one of the most common locations of thoracic aortic aneurysms, have often been excluded from stent-graft repair because of the frequently encountered size mismatch and insufficient length of the proximal landing zone. A larger sized endoprothesis with higher profile and rigidity of introducer has to be compromised with a smaller vascular conduit, especially for Asian patients.…”

Hybrid-repair of thoraco-abdominal or juxtarenal aortic aneurysm: what the radiologist should know

“…A minimum distance of 15-20 mm is recommended for successful insertion and stability of the endograft [27,28]. Unfavourable neck morphology with circumferential thrombus or atherosclerotic plaque is an exclusion criterion for EVAR.…”