Invited commentary

Abstract

Endovascular thoracoabdominal aortic aneurysm (eTAAA) repair is emerging as a valid option in select centers. Some important observations can be drawn from the current study. First, in the short term, a multibranched device with caudally oriented cuffs seems to be an anatomically versatile device for eTAAA treatment. Second, the use of an “off-the-shelf” device restricts the anatomical suitability but offers the significant advantage of immediate access. Third, the applicability of a multibranched device in the setting of postdissection aneurysms is quite low. The anatomical limitations of the multibranched stent graft are related to iliac access and visceral artery anatomy. Access issues are common with endovascular aneurysm repair in general, but are emphasized in eTAAA where adequate access is paramount not only for delivering the device but also for positioning it in relation to the visceral vessels. In addition, the critical need for preservation of collateral flow to the spinal cord via the hypogastric arteries makes access even more important. However, as the authors point out, the assessment of iliac vessel morphology was subjectively measured, and as such, the significance and applicability of these criteria are very questionable. The current reporting standards for iliac artery assessment are likewise nonvalidated in clinical practice, and this remains a significant flaw in the literature when reporting on “poor” access for endovascular aneurysm repair. Clearly, a robust, simple method for reporting access morphology must be established to allow for better interpretation of applicability and outcomes.1Kristmundsson T. Sonesson B. Resch T. A novel method to estimate iliac tortuosity in evaluating EVAR access.J Endovasc Ther. 2012; 19: 157-164Crossref PubMed Scopus (26) Google Scholar The main question that remains unanswered by the current report is to what degree the wide application of a single stent graft design affects long-term outcome? The fact that immediate technical success can be achieved clearly does not say much about this. This is even truer for a completely fixed “off-the-shelf” design, which should be viewed as an addition in the treatment arsenal and not a substitute for custom-made designs. Uniformly applying caudally oriented cuffs in the setting of cranially directed target vessels or in narrow aortic segments might have significant negative effects on both short- and long-term target vessel patency.2Resch T. Sonesson B. Malina M. Incidence and management of complications after branched and fenestrated endografting.J Cardiovasc Surg (Torino). 2010; 51: 105-113PubMed Google Scholar In this regard, stent graft designs incorporating both branches and fenestrations to achieve an optimal fit might be a better path to take.3Greenberg R.K. Lu Q. Roselli E.E. Svensson L.G. Moon M.C. Hernandez A.V. et al.Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques.Circulation. 2008; 118: 808-817Crossref PubMed Scopus (432) Google Scholar We are eagerly awaiting the long-term outcome data on eTAAA repair to answer some of these questions and thank the University of California San Fransisco group for their continued groundbreaking work in this very exciting field. Assessing the anatomic applicability of the multibranched endovascular repair of thoracoabdominal aortic aneurysm techniqueJournal of Vascular SurgeryVol. 57Issue 6PreviewMultibranched endovascular aneurysm repair (MBEVAR) has the potential to lower the morbidity and mortality rates of thoracoabdominal aneurysm repair, but the applicability of the technique is unknown. Our aim was to estimate the prevalence of anatomic suitability for MBEVAR. Full-Text PDF Open Archive