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      Standard of Practice for the Endovascular Treatment of Thoracic Aortic Aneurysms and Type B Dissections

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          Abstract

          Thoracic endovascular aortic repair (TEVAR) represents a minimally invasive technique alternative to conventional open surgical reconstruction for the treatment of thoracic aortic pathologies. Rapid advances in endovascular technology and procedural breakthroughs have contributed to a dramatic transformation of the entire field of thoracic aortic surgery. TEVAR procedures can be challenging and, at times, extraordinarily difficult. They require seasoned endovascular experience and refined skills. Of all endovascular procedures, meticulous assessment of anatomy and preoperative procedure planning are absolutely paramount to produce optimal outcomes. These guidelines are intended for use in quality-improvement programs that assess the standard of care expected from all physicians who perform TEVAR procedures.

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          Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms.

          Alexander R P Walker, Michael D. Dake, Robert Miller … (1994)
          The usual treatment for thoracic aortic aneurysms is surgical replacement with a prosthetic graft, but the associated morbidity and mortality are considerable. We studied the use of transluminally placed endovascular stent-graft devices as an alternative to surgical repair. We evaluated the feasibility, safety, and effectiveness of transluminally placed stent-graft to treat descending thoracic aortic aneurysms in 13 patients over a 24-month period. Atherosclerotic, anastomotic, and post-traumatic true or false aneurysms and aortic dissections were treated. The mean diameter of the aneurysms was 6.1 cm (range, 5 to 8). The endovascular stent-grafts were custom-designed for each patient and were constructed of self-expanding stainless-steel stents covered with woven Dacron grafts. Endovascular placement of the stent-graft prosthesis was successful in all patients. There was complete thrombosis of the thoracic aortic aneurysm surrounding the stent-graft in 12 patients, and partial thrombosis in 1. Two patients initially had small, residual patent proximal tracts into the aneurysm sac, but both tracts thrombosed within two months after the procedure. In four patients, two prostheses were required to bridge the aneurysm adequately. There have been no deaths or instances of paraplegia, stroke, distal embolization, or infection during an average follow-up of 11.6 months. One patient with an extensive chronic aortic dissection required open surgical graft replacement four months later because of progressive dilatation of the arch. These preliminary results demonstrate that endovascular stent-graft repair is safe in highly selected patients with descending thoracic aortic aneurysms. This new method of treatment will, however, require careful long-term evaluation.
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            Aortic dissection: new frontiers in diagnosis and management: Part I: from etiology to diagnostic strategies.

            Christoph Nienaber, Kim Eagle (2003)
            Article 0 comments Cited 114 times – based on 0 reviews     Review now
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              What is the appropriate size criterion for resection of thoracic aortic aneurysms?

              Anne Coady, J Elefteriades, Brandy L. Hammond … (1997)
              Although many articles have described techniques for resection of thoracic aortic aneurysms, limited information on the natural history of this disorder is available to aid in defining criteria for surgical intervention. Data on 230 patients with thoracic aortic aneurysms treated at Yale University School of Medicine from 1985 to 1996 were analyzed. This computerized database included 714 imaging studies (magnetic resonance imaging, computed tomography, echocardiography). Mean size of the thoracic aorta in these patients at initial presentation was 5.2 cm (range 3.5 to 10 cm). The mean growth rate was 0.12 cm/yr. Overall survivals at 1 and 5 years were 85% and 64%, respectively. Patients having aortic dissection had lower survival (83% 1 year; 46% 5 year) than the cohort without dissection (89% 1 year; 71% 5 year). One hundred thirty-six patients underwent surgery for their thoracic aortic aneurysms. For elective operations, the mortality was 9.0%; for emergency operations, 21.7%. Median size at time of rupture or dissection was 6.0 cm for ascending aneurysms and 7.2 cm for descending aneurysms. The incidence of dissection or rupture increased with aneurysm size. Multivariable regression analysis to isolate risk factors for acute dissection or rupture revealed that size larger than 6.0 cm increased the probability by 32.1 percentage points for ascending aneurysms (p = 0.005). For descending aneurysms, this probability increased by 43.0 percentage points at a size greater than 7.0 cm (p = 0.006). If the median size at the time of dissection or rupture were used as the intervention criterion, half of the patients would suffer a devastating complication before the operation. Accordingly, a criterion lower than the median is appropriate. We recommend 5.5 cm as an acceptable size for elective resection of ascending aortic aneurysms, because resection can be performed with relatively low mortality. For aneurysms of the descending aorta, in which perioperative complications are greater and the median size at the time of complications is larger, we recommend intervention at 6.5 cm.
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                Author and article information

                Contributors
                : fabrizio.fanelli@uniroma1.it
                Journal
                Journal ID (nlm-ta): Cardiovasc Intervent Radiol
                Title: Cardiovascular and Interventional Radiology
                Publisher: Springer-Verlag (New York )
                ISSN (Print): 0174-1551
                ISSN (Electronic): 1432-086X
                Publication date (Electronic): 18 August 2009
                Publication date (Print): September 2009
                Volume: 32
                Issue: 5
                Pages: 849-860
                Affiliations
                [1 ]Department of Radiological Sciences, Vascular and Interventional Radiology Unit, “Sapienza,” University of Rome, 324 Viale Regina Elena, 00161 Rome, Italy
                [2 ]Department of Cardiothoracic Surgery Radiology, Stanford University School of Medicine, Falk Cardiovascular Research Center, 300 Pasteur Drive, Stanford, CA 94305-5407 USA
                Article
                Publisher ID: 9668
                DOI: 10.1007/s00270-009-9668-6
                PMC ID: 2744786
                PubMed ID: 19688371
                SO-VID: 7cd1df35-dfb7-4838-aae1-c3574b9cc3fd
                Copyright © © The Author(s) 2009
                History
                Date received : 25 June 2009
                Date accepted : 8 July 2009
                Categories
                Subject: Cirse Guidelines
                Custom metadata
                issue-copyright-statement © Springer Science+Business Media, LLC and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2009

                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: aortic dissection,standard of practice,thoracic aortic aneurysm,cirse,thoracic aorta
                Data availability:
                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: aortic dissection, standard of practice, thoracic aortic aneurysm, cirse, thoracic aorta

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