Role of Endovascular Therapies in the Management of Diverse Thoracic Aortic Pathology

Abstract

Stent grafts are currently indicated for treatment of chronic aneurysmal disease of the descending thoracic aorta. At most centers of excellence, this technique has become the preferred treatment modality for this pathologic process. Many centers are also reporting excellent outcomes using a variety of debranching procedures to expand the anatomic limits of therapeutic intervention. These debranching procedures enable proximal extension of stent grafts into the transverse aortic arch and similarly enable distal extension into the visceral portion of the abdominal aorta. Thoracic aortic disease, however, is not limited to aneurysmal pathology. In our experience, at least half of all patients with major thoracic aortic pathology will have nonaneurysmal disease processes. Frequently, these patients are high-risk candidates for the performance of open surgical intervention. The reduced procedural morbidity and mortality observed with thoracic endovascular aortic repair when compared with open surgical intervention have catalyzed the investigation of stent grafts in the management of nonaneurysmal pathologic processes. This therapy has been successfully applied to a variety of diverse thoracic aortic pathologies, including aortic dissection, aortic transection, penetrating atherosclerotic ulcers, embolic lesions, and aortic coarctation. The focus of this article is on the latter 3 of these pathologies.

What to Do When Evidence is Lacking — Implications on Treatment of Aortic Ulcers, Pseudoaneurysms and Aorto-Enteric Fistulae

“…Authorities in this area recommend conservative therapy in asymptomatic patients and to consider the evolving and attractive treatment with endovascular stent grafts (12). The number of small case series regarding endovascular treatment of PAUisrapidly increasing (13)(14)(15)(16)(17)(18)(19)(20). In the review by Forda nd Farber (13) comprising 133 patients treated endovascularly,non-successful deployment of the stent graft was only reported in three patients.…”

Complex aortic disease: Changes in perception, evaluation and management

“…[44][45][46] A recent review of penetrating aortic ulcer described the risk of death, endoleak, and spinal ischemia in the available published series and found that perioperative mortality ranges from 0% to 12%. 47 One high-volume center that uses central aortic fenestration and renal artery stenting as a treatment for malperfusion complicating acute dissection reports a perioperative mortality of 21%. 44 Other groups, reporting on their experience in both the acute and chronic thoracic aortic population, found a perioperative mortalities of 5% to 16%, but these results are difficult to interpret because of the heterogeneity of the patients undergoing intervention.…”

Are Aortic Stent Grafts Safe in Pregnancy?

“…In recent years there has been an exponential rise in the use of aortic stent grafts. Besides aneurysm repair, aortic stent grafts are also useful in acute and chronic aortic dissections, traumatic transections of the aorta, and selected cases of coarctation of the aorta [ 1 ]. A detailed literature review failed to show limited information about the use and safety of aortic stent grafts in pregnant women.…”