Total Endovascular Repair for Thoraco-abdominal Aneurysms: Not for All, Not for Now

Abstract

Thoraco-abdominal aneurysms (TAAs) represent a surgical challenge due to the complex surgical strategy to extensively replace the visceral aorta preventing multiple-organ ischaemia. The very unlikely opportunity of a mini-invasive approach for TAA, due to the several arterial branch involvement, seems to have become a real therapeutical choice in the last few years. Increasing evidence supports the feasibility of TAA repair with a total endovascular procedure, as shown by the study of Clough et al. in this issue of EJVES reporting the largest experience in the UK with this technique.1Clough RE, Modarai B, Bell R, Salter R, Sabharwal T, Taylor P, et al. Total endovascular repair of thoracoabdominal aortic aneurysms. J Vasc Endovasc Surg, in press.Google Scholar The authors collected 31 totally endovascular TAA repairs using custom-made endografts in a cohort considered at high-risk for open surgery and achieved early results comparable to those obtained with hybrid or surgical repair in average-risk patients. Thirty-day mortality was 9.7% (3/31) and only one patient (3.1%) presented late-onset paraparesis and a second (3.1%) developed acute renal failure after 8 months. In 32.7% of patients, deterioration of renal function was detected after treatment. There were no conversions to open repair and, of the overall three endoleaks, only one was type III originating from a coeliac bridging stent and requiring reintervention. A number of key messages can be learnt from an experience like this on present-day total endovascular management of TAA. Total endovascular repair of TAAs, although feasible, is not for all. A successful procedure requires adequate operator training, centre competence, custom-made devices and, of more importance, careful assessment of TAA suitability. Even though Clough et al. reported the largest experience in the UK, the study was a relatively small single-centre experience with only 31 patients recruited.1Clough RE, Modarai B, Bell R, Salter R, Sabharwal T, Taylor P, et al. Total endovascular repair of thoracoabdominal aortic aneurysms. J Vasc Endovasc Surg, in press.Google Scholar Concerns remain as to whether and to which extent the total endovascular treatment can be generalised to common TAA patients. TAA is a very challenging disease and operative risks are not trivial even with the lesser invasiveness of an endovascular approach. Perioperative mortality, paraplegia and renal failure are still important concrete risks. However, the report by Clough et al.1Clough RE, Modarai B, Bell R, Salter R, Sabharwal T, Taylor P, et al. Total endovascular repair of thoracoabdominal aortic aneurysms. J Vasc Endovasc Surg, in press.Google Scholar analysed data related to higher-risk patients for whom the new technology was the only treatment option and included all the cases treated by the authors since the application of a total endovascular approach reflecting their learning curve experience. With technology development and accumulated experience, improved results should be likely obtained in the near future and the technique may be extended to patients at a standard surgical risk. There are few data to provide the efficacy and the long-term durability of total endovascular repair. The paper of Clough et al. showed mainly 30-day results.1Clough RE, Modarai B, Bell R, Salter R, Sabharwal T, Taylor P, et al. Total endovascular repair of thoracoabdominal aortic aneurysms. J Vasc Endovasc Surg, in press.Google Scholar Lack of conversions to open surgery and a single case of endoleak requiring reintervention seem to be reassuring but the median 12-month follow-up reached in the study needs to be supported by longer evaluations. Endovascular repair of TAA is not for routine now. The technique is not straightforward and it is applicable in centres with high level of expertise and custom-made devices availability. However, technology is continually evolving. Appropriate training, suited device planning and careful patient selection make this very appealing new approach to TAA an extremely delicate choice that would hopefully expand in the near future. Nevertheless, despite the mini-invasiveness of the new total endovascular repair, TAA repair will remain a very demanding procedure. None.