Systematic review and reconstructed individual patient data of atherosclerotic subclavian artery aneurysm in the endovascular era.

Recently published long-term outcomes of the UK Endovascular Abdominal Aortic Aneurysm Repair (EVAR) trial investigators and the Dutch Randomized Endovascular Aneurysm Repair group have continued to demonstrate the superiority of EVAR in the perioperative period, but they have failed to establish long-term sustainable durability compared to open repair because of increased graft-related complications and reinterventions.1,2 In 2005, thoracic endovascular aneurysm repair (TEVAR) was approved in the United States for the treatment of descending thoracic aortic aneurysms (DTAAs). This approval, based on the results of a phase II trial3 evaluating the GORE TAG endovascular prosthesis (W.L. Gore and Associates, Newark, Delaware), led to a nationwide explosion in the use of thoracic endovascular techniques for managing DTAAs.4 Physicians had already been performing EVAR for more than a decade. Whereas EVAR was initially used to repair abdominal aneurysms with a favorable anatomy, its use later expanded to include complex cases involving a short aneurysmal neck, a tortuous aorta, and (more recently) aneurysmal rupture. Although TEVAR has only a brief history, a similar trend is obvious: This approach is being used with reasonable success to treat dissections and even ruptured aneurysms5; in addition, various new debranching techniques are allowing TEVAR to be applied to portions of the aorta previously deemed unapproachable. Article see p 2718 Najibi and colleagues6 reported the results of the first study to compare TEVAR with open aortic repair. Their series comprised 18 patients, and the control group included a historic cohort of patients who had undergone open aortic repair during the previous 3 years. Short-term follow-up data showed that the endovascular group had significantly shorter operative times, shorter hospital and intensive-care–unit stays, and less operative blood loss. Subsequently, Bavaria and associates7 reported the results of a phase II multicenter trial that assessed GORE …

Intrathoracic subclavian artery aneurysm repair in the thoracic endovascular aortic repair era

Invited commentary

Management of visceral aortic patch aneurysms after thoracoabdominal repair with open, hybrid, or endovascular approach

Volume-Outcome Relationships and Abdominal Aortic Aneurysm Repair

Hybrid Endovascular Treatment of an Anomalous Right Subclavian Artery Dissection in a Patient With Marfan Syndrome

Conventional open repair for proximal subclavian artery aneurysms (SCAAs) requires cardiopulmonary bypass. However, patients with proximal SCAA can be treated with hybrid repair. Between 2007 and 2012, we performed hybrid repair to treat six consecutive patients with proximal SCAA (three left SCAAs, one right aberrant SCAA, two right SCAAs). Their median age was 73.5 [70-87] years, and the size of their aneurysm was 33.5 [30-45] mm. Thoracic endovascular aneurysm repair (TEVAR) only was used for one patient with left SCAA, TEVAR and supra-aortic bypass for two with left SCAA and one with right aberrant SCAA, and endovascular repair with reconstruction of the vertebral artery using the saphenous vein graft (SVG) for two with right SCAA. The follow-up duration was 3.7 [0.2-6.8] years. There was no 30-day mortality and only one early complication consisting of a minor stroke after TEVAR for shaggy aorta. Two late deaths occurred, one caused by cerebral infarction due to occlusion of SVG to the dominant vertebral artery 2 months after the operation and the other by aortic dissection 5 years postoperatively. Hybrid repair can be a less-invasive alternative for proximal SCAA. Revascularization of neck vessels and TEVAR should be performed very carefully to prevent neurologic complications.

Recent years have witnessed the emergence of novel technologies that enable less invasive endovascular treatment of descending thoracic aortic disease (TAD). This has occurred against a backdrop of improved identification of various disease processes and better results with open surgical repair. The natural history of the specific acute aortic syndromes that affect the descending thoracic aorta has also been described with more clarity and has become more commonly recognized. This is in part secondary to the widespread availability and application of advanced imaging technologies that permit precise diagnoses. As data are accumulating, these pathological processes involving the descending thoracic aorta are no longer thought of as simply variants of one another but as distinct entities with well-defined clinical behavior. As the technology for endovascular repair continues to mature and its utilization increases, there is a need for a careful assessment of the current state of medical management, traditional open therapy, and evolving endovascular treatment of distinct thoracic aortic pathologies. The purpose of this scientific statement is to present a contemporary review of the various pathological processes that affect the descending thoracic aorta: Aneurysms, dissections, intramural hematomas (IMHs), penetrating atherosclerotic ulcers (PAUs), and aortic transections. These disorders will be considered in detail, with an exploration of the natural history, available treatment options, and controversies regarding management. Current intervention criteria will be reviewed with respect to both open surgical repair and endovascular treatment. Our goal is to provide the healthcare professional with a better understanding of the pathophysiology of the various disease processes that involve the descending thoracic aorta and to review current outcomes and technical pitfalls associated with these therapies to facilitate strong, evidence-based decision making in the care of these patients. Treatment of descending TAD involves complex, exigent decision making in an era of evolving technology. Survival data for nonoperative …

Long-term Survival After Endovascular Repair for Intact Infrarenal Abdominal Aortic Aneurysms is Improving Over Time

The modern open surgical management of abdominal aortic aneurysm (AAA) has changed little since its inception in the 1950s. Endoaneurysmorrhaphy, first described by Rudolph Matas in 1888, involved ligating the branches of an aneurysm from within the aneurysm sac. Approximately 25 years later at the

Open and Endovascular Repair of Popliteal Artery Aneurysms

Hybrid Treatment for Ruptured Diverticulum of Kommerell: A Minimally Invasive Option

Introduction Subclavian artery aneurysm (SAA) is an uncommon entity, and there is little information in the vascular ultrasound literature regarding this disorder. Methods Query of a single-center noninvasive vascular laboratory database for all duplex examinations performed from January 1, 2000, to December 31, 2009 with a diagnosis of SAA. Medical records, archived ultrasound images, and correlative imaging studies were reviewed. Result A total of 12 patients with SAA were identified. Median age 56 years (range, 24–86 years), 58% male. The etiology of SAA was as follows: atherosclerosis (3/12), thoracic outlet syndrome (TOS; 3/12), connective tissue disorder (3/12), trauma (2/12), and vasculitis (1/12). All patients with SAA not caused by TOS had additional peripheral arterial or aortic aneurysm(s) previously or subsequently documented on imaging studies. Ten patients had symptoms at the time of diagnosis, most commonly arm and neck pain, arm claudication, and neurological findings. Aneurysms were equally distributed between right and left sides. The majority of SAA (9/12) were located at the origin or proximal subclavian artery; 3 were dissecting aneurysms. The median aneurysm maximal diameter was 2.35 cm (range, 1.5–6.4 cm), and the median contiguous normal artery diameter was 0.85 cm. Three patients had significant velocity shifts noted within the aneurysm. Vertebral artery flow was abnormal in one-third of SAA (4/12). Marked tortuosity of either internal carotid artery was a common related finding among these patients (6/12). Correlative computed tomography scan was available for 5 patients. A total of 75% of subjects in this series underwent open or endovascular aneurysm repair, whereas the remaining patients were followed with no intervention. Conclusion Duplex ultrasound is a useful tool for diagnosis and characterization of subclavian artery aneurysms. Among patients with SAA who have no evidence of TOS, careful evaluation for co-existent aortic and peripheral aneurysms is critical.

Aortic Dissection in the Presence of an Aberrant Right Subclavian Artery

Aneurysmectomy With Arterial Reconstruction of Renal Artery Aneurysms in the Endovascular Era: A Safe, Effective Treatment for Both Aneurysm and Associated Hypertension