Emergency Procedures on the Descending Thoracic Aorta in the Endovascular Era

Abstract

Thoracic endovascular aortic repair (TEVAR), initially developed for the treatment of degenerative aneurysms of the descending thoracic aorta, has been applied to the entire spectrum of descending thoracic aortic pathology in both the elective and emergent settings. This single center study evaluates the effectiveness of TEVAR for the treatment of acute surgical emergencies involving the descending thoracic aorta, including traumatic aortic disruption (TAD), ruptured descending thoracic aneurysm (RDTA), and acute complicated type B dissection (cTBD). A retrospective review of the medical records of all patients undergoing emergent TEVAR at a tertiary care medical center with a level 1 trauma center between August 2007 and August 2010 was undertaken. Study endpoints included: 30-day survival, complications, type of device used for the repair and technical aspects of the procedure. A total of 42 patients (62% male) with an average age of 50 years underwent emergent TEVAR during the study period. The technical success rate was 100%, with no patient requiring emergent open surgery for conditions involving the descending thoracic aorta at our institution during the study period. The majority (71%) of the repairs were accomplished using commercially available thoracic stent grafts. Abdominal stent graft components were used in 40% of patients undergoing repair of TAD. Twenty patients (48%) required coverage of the left subclavian artery, two of whom subsequently required subclavian artery revascularization. Procedure related complications included: 1 stroke, 1 spinal cord ischemia, 1 unintentional coverage of the left carotid artery, 1 episode of acute renal failure and 2 access site injuries. Two patients undergoing repair of TAD had collapse of the stent graft in the early postoperative period. Both were successfully treated by placement of an additional stent graft. Seven patients (17%) died within 30 days of surgery. Three had successfully undergone repair of a TAD and died of associated injuries.Tabled 1Type of aortic pathologyMean age (range)Type of deviceSubclavian artery coverage30-day survivalTAD43 (16-77)Thoracic-1815 of 30 (50%)27 of 30 (90%)N = 30Abdominal-12RDTA68 (54-87)Thoracic - 73 of 7 (43%)4 of 7 (57%)N = 7cTBD67 (50-77)Thoracic-42 of 4 (50%)3 of 4 (75%)N = 4Distal aortic tear42Thoracic-101/1 (100%)N = 1Total50 (16-87)Thoracic-3020 of 42 (48%)35 of 42 (83%)N = 42Abdominal-12 Open table in a new tab Emergent TEVAR has become the treatment of choice for acute surgical emergencies involving the descending thoracic aorta. Short-term results compare favorably to published historic results for emergent open surgical procedures on the descending thoracic aorta. Survival is highest in patients undergoing repair of TAD. Using current stent graft technology, nearly all emergent conditions of the descending thoracic aorta can be successfully treated with TEVAR. Subclavian artery coverage is required in half of patients, and can be performed safely. A minority will subsequently require subclavian artery revascularization.