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Key Concepts

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  • Traditional open surgical repair of thoracic aortic disease is associated with significant morbidity and mortality.

  • Endovascular stent-graft therapies have emerged as a minimally invasive approach to treating thoracic aortic pathologies.

  • Stent-graft devices consist of membrane material mounted on an expandable metal stented framework.

  • Although several imaging modalities have proved useful in planning and executing stent-graft deployment, computed tomography has emerged as the dominant imaging modality because of its wide availability, high resolution, and ability to obtain a variety of three-dimensional reconstructions of the thoracic and abdominal aorta.

  • Endovascular stent grafts are deployed through sheaths placed in the common femoral or iliac artery. It is often useful to obtain vascular access through an extension conduit anastomosed to the common iliac artery via a retroperitoneal approach.

  • There are four types of “endoleaks,” or seepage of blood between the walls of the aorta and/or from graft material.

  • Endovascular stent grafts have been used to repair aortic aneurysms, Stanford type B aortic dissections, penetrating atherosclerotic ulcers, and traumatic aortic transections. The results of these repairs are promising but still are accumulating.

  • Complications of endovascular stent-graft repairs of the thoracic aorta include spinal cord ischemic injury, retrograde aortic dissection, and iliofemoral arterial injury.

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Introduction

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Traditional open surgical repair of thoracic aortic disease continues to be associated with significant morbidity and mortality. Endovascular stent grafts have emerged as an exciting new technology to treat thoracic aortic pathologies. This minimally invasive approach decreases operative risk by minimizing aortic manipulation, avoiding large incisions and surgical hemorrhage, and circumventing the complications associated with cardiopulmonary bypass. This chapter presents the advantages and challenges of thoracic endovascular aortic repair (TEVAR) of the following pathologies of the thoracic aorta: aneurysm, dissection, penetrating atheromatous ulcers, intramural hematomas (IMHs), and traumatic lesions.

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Comparative Results of Open Repair

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Before one begins a review of endovascular repair of thoracic aortic pathology, a review of the current state of open thoracic replacement is required. It is important to draw the clinical distinction between descending thoracic aortic (DTA) replacement and thoracoabdominal aortic (TAA) replacement. The current literature is replete with series of studies of TAA surgery,1 but series detailing the results of lesser thoracic aortic operations are sparse. In DTA replacement, the duration of renal–visceral ischemia is minimal as the thoracic aortic anastomosis often can be accomplished with less than 30 min of aortic interruption. Indeed, if distal perfusion techniques are employed, renal–visceral ischemia may be avoided completely. Thus, extrapolating the series detailing TAA replacement to the arena of DTA replacement overestimates the attendant risk of the pathologies now being addressed by endovascular means. Nonetheless, reviewing the literature of thoracic aortic replacement elucidates the risks both avoided (large cavitary incisions and blood loss) and assumed (paraplegia).

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The largest series reporting results of DTA surgery for repair of degenerative aneurysms—not thoracoabdominal aneurysms (TAAs)—was published by Coselli and associates in 2004.2 This ...

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