Reply

Abstract

We appreciate Dr Verdant's comments regarding our recent article describing our experience with endovascular stent graft repair of thoracic aortic aneurysms. There are a few comments we would specifically like to address. Dr Verdant states that we have clearly established the “poor performance” of this technology, implying that the 33% mortality at 40 months is aneurysm related. This is incorrect. As is clearly stated in the article, 6 deaths were attributable to aneurysm-related causes. The rest were from underlying comorbid medical illnesses. With regards to the Type I endoleak rate, we have adopted a more liberal approach to performing combined open and endovascular repairs of thoracic aneurysms. Since the time of publication, we have enrolled 18 more patients in our protocol, all using the Talent device. Of these 18 patients, 7 had their stent graft as the second stage of an elephant trunk repair. The results in these 18 patients have been heartening. We achieved primary clinical success in 17; in 1 patient, we were unable to deliver the device due to aortic tortuosity. There were 2 mortalities in this cohort: 1 from infective endocarditis which was present at the time of initial presentation, and 1 from a ruptured infrarenal aneurysm. There were no major procedure-related morbidities. There were no thoracic aneurysm– or device-related deaths. There were no Type I or Type III endoleaks. We agree wholeheartedly with Dr Verdant's sentiment that these cases should be done in “highly specialized centers for aortic surgery equipped with fully trained personnel and optimal methods of organ protection.” As a matter of fact, our multidisciplinary team includes a group of cardiac surgeons with extensive experience in open thoracic aneurysm repair. The cases are reviewed as a group, and the most appropriate course of therapy is decided upon. Thoracic stent-graft technology is still very much in evolution, and we recognize that it is still investigational. One of the goals of our article was to bring to light the limitations of current technology. However, one should be careful not to “throw out the baby with the bathwater.” Dr Verdant states that any “technique of graft insertion in which the adventitia is… excluded is doomed to failure.” Clinical data clearly suggests otherwise. The evolving experience with endovascular stent-graft repair of infrarenal abdominal aortic aneurysms has shown us that endoluminal aneurysm exclusion results in a durable and safe repair with decreased morbidity in properly selected patients.1Marin ML, Hollier LH, Ellozy SH, Spielvogel D, Mitty H, Griepp R, Lookstein RA, Carroccio A, Morrissey NJ, Teodorescu VJ, Jacobs TS, Minor ME, Sheahan CM, Chae K, Oak J, Cha A. Endovascular stent graft repair of abdominal and thoracic aortic aneurysms: a ten-year experience with 817 patients. Ann Surg 2003 Oct;238:586-95Google Scholar We feel confident that with improvements in patient selection, device delivery systems, and stent-graft design, the same will be true for the thoracic aorta. The analogy can be made to the evolution of the prosthetic cardiac valve, a process that took more than 15 years. Think how many people would not be alive today if the development process had been abandoned because of early failures.