Editors' commentary

Abstract

Aortic-specific reinterventions are more common after endovascular repairs than after traditional open procedures, and as a result, postoperative surveillance has been a mandatory component of endovascular therapy. In the abdominal aorta this has led to a recommendation for regular and lifelong computed tomography imaging, which has only recently been modified to include less radiation-intensive monitoring techniques. Surveillance after thoracic endovascular aortic repairs (TEVAR) offers several differences compared with those in the abdominal aorta. Abdominal aortic pathologies are more uniform than in the thorax, with most abdominal aortic stent grafts performed for aneurysmal disease. In the thoracic aorta, TEVAR is used in disparate pathologies, including aneurysms, dissections, traumatic injuries, penetrating ulcers, and intramural hematomas. In addition, traditional ultrasound imaging techniques currently have little utility in the thoracic aorta, which limits radiologic surveillance mainly to imaging with computed tomography (CT), magnetic resonance (MR), and plain radiographs. More extensive thoracic pathologies, such as aneurysms and dissections, have post-TEVAR complications more similar to abdominal stent grafts, namely progressive aortic dilatation and endoleaks. It seems appropriate to continue to regularly survey these patients indefinitely with cross-sectional imaging techniques and to include the abdominal aorta because these pathologies commonly represent pan-aortic disease. Blunt traumatic injuries to the proximal descending thoracic aorta are another story. Typically, these are focal injuries of a previously normal aorta in younger patients. Complications have mainly been seen in the short-term and include unsuccessful exclusion of the injury and endograft infolding. Longer-term aortic dilatation has been observed, but is slow and of uncertain clinical significance.1Forbes T.L. Harris J.R. Lawlor D.K. Derose G. Aortic dilatation after endovascular repair of blunt traumatic thoracic aortic injuries.J Vasc Surg. 2010; 52: 45-48Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar With these patients, it is reasonable to lengthen the interval between surveillance imaging and to augment and replace the occasional CT scan with plain chest x-ray imaging. The disadvantage of this may be the increased number of these generally young and mobile trauma patients who are lost to follow-up. Whether they present decades later with currently unforeseen complications is a concern and remains to be seen. With the varying pathologies currently managed with TEVAR, it is prudent to adopt more anatomic and pathologic specific follow-up regimens and intervals. Annual CT or MR follow-up may not be needed in all patients, but lifelong surveillance is still recommended. Consequently, both groups of debaters are at least partially correct. The role of mandatory lifelong annual surveillance after thoracic endovascular repairJournal of Vascular SurgeryVol. 56Issue 6PreviewThoracic endovascular aortic repair (TEVAR) has become an attractive and well-accepted option for the management of the various thoracic aortic pathologies that vascular surgeons are confronted with. As in the abdominal aorta, current management trends include the treatment of younger patients with longer life expectancies, raising the issue of postoperative surveillance. There are several relevant differences between these anatomic areas when it comes to surveillance, including the relative inaccessibility of the thoracic aorta to ultrasound interrogation and the increased variability of thoracic aortic pathologies and post-TEVAR complications. Full-Text PDF Open Archive