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Patients with thoracic aortic disease are a difficult population to treat, because they frequently consist of an aged population with multiple comorbidities. The modern surgical treatment of thoracic aortic diseases began in the 1950s when successful treatment using segmental resection and graft replacement was reported by Swan, Lam, DeBakey, and Etheredge.1–3 Thereafter, DeBakey and Cooley reported the first successful repair of an ascending aortic aneurysm using cardiopulmonary bypass.4 Our understanding of the pathophysiology and natural history of thoracic aortic disease has evolved, which has expanded our treatment choices.5,6 In addition, improvements in diagnostic capabilities, surgical techniques, and perioperative care have resulted in improved outcomes, even as the risk profile has increased. Nonetheless, operative intervention in this patient population frequently results in substantial mortality and long-term morbidity.7,8 The concept of using endovascular techniques to treat patients with thoracic aortic disease emerged a decade ago, propelled by the desire to avoid surgical risk as well as to induce reconstructive modeling of the diseased aorta by initiating a natural healing process through exclusion and depressurization of the aneurysmal sac.9 In an effort to improve outcomes in the treatment of patients with thoracic aortic disease, endovascular stent-graft technology has rapidly followed applications on the abdominal aorta.10,11 Originally devised for high-risk patients with multiple comorbidities, thoracic stent-graft applications are being expanded to young and old patients with a variety of pathologies, including thoracic aortic aneurysms, aortic dissections, intramural hematomas, penetrating atherosclerotic ulcers, and thoracic aortic trauma.12–19 Initial reports using these endovascular stent-grafts have been encouraging, but long-term outcomes are unknown, and the necessity for long-term follow-up, with its attendant expense, has raised serious concern.20–22

Endovascular stent-graft technology was initially envisioned for use in abdominal aortic aneurysms.23 Introduced by Parodi, balloon-expandable stents attached to the ends of a vascular tube graft were used to exclude the aneurysm sac. There were several attractive features of this concept, including the introduction of the device from a peripheral site, eliminating the necessity for an invasive laparotomy, the avoidance of aortic cross-clamping and its requisite physiologic perturbations, and minimizing respiratory complications. Last, hospital stay and recovery time could be potentially shortened.

At Stanford University Medical Center, a collaborative effort between interventional radiologists and cardiovascular surgeons proved highly synergistic, and resulted in the manufacture and clinical use of thoracic stent grafts. Work had commenced years earlier with the use of uncovered stents for the repair of aortic dissections in an animal model. The stent grafts were manufactured using self-expanding Gianturco Z stents (Cook Co., Bloomington, IN), which were fastened together and then covered with a woven Dacron graft (Meadox-Boston Scientific, Natick, MA; Fig. 54-1). Institutional review board (IRB) approval was initially obtained for a high-risk study using endovascular stent-grafts for the treatment of thoracic aortic aneurysms in patients who were deemed not to be surgical candidates.24 A total of 13 patients underwent transluminal endovascular grafting ...

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