What Can We Learn From MOTHER?

Abstract

In 1953, DeBakey and Cooley1 successfully resected a large aneurysm of the descending thoracic aorta and replaced it with a homograft by using a clamp-and-sew approach. The techniques used in contemporary open surgical repair by synthetic graft replacement are essentially unchanged since the early days of descending thoracic aortic repair. In the 1980s, Volodos et al2 and Parodi and colleagues3 pioneered the use of endovascular aortic stent grafts to repair thoracic and abdominal aortic aneurysms. Soon thereafter, Dake et al4 were instrumental in popularizing their use to repair descending thoracic aortic aneurysms. Pivotal trials (with stringent patient selection) were performed to establish the noninferiority of this newly emerging technology compared with standard open repair of aortic aneurysm.5,6 Concurrent open surgical controls were not used in any of the clinical trials targeted for US Food and Drug Administration approval. Article see p 24 The primary goal of both open and endovascular aortic aneurysm repair is to prevent death as a result of aortic rupture. Although early outcomes clearly favor endovascular therapy, the superiority of one technique over another has not yet been firmly established for thoracic endovascular aortic repair (TEVR), because long-term data are still lacking. Since the Food and Drug Administration approved TEVR in 2005, the use of this approach to treat thoracic aortic pathology has grown. This growth includes off-label applications of TEVR, such as treating acute and chronic aortic dissection. It is estimated that currently, off-label applications constitute well over half of all TEVRs.7,8 Although the use of TEVR as a definitive treatment for either acute9 or chronic10 aortic dissection remains controversial, its use in emergent, complicated cases of acute DeBakey type III aortic dissection is generally considered acceptable and potentially lifesaving; in fact, in many …