Treatment Of Thoracic Aortic Aneurysms Research Articles

Endovascular Exclusion of Thoracic Aortic Aneurysms With the 1- and 2-Component Zenith TX2 TAA Endovascular Grafts: Analysis of 2-Year Data From the TX2 Pivotal Trial

To compare the midterm results of endovascular treatment of thoracic aortic aneurysms and ulcers in patients who received either a 1-component or 2-component Zenith TX2 stent-graft. Data were gathered from a prospectively maintained registry for the Zenith TX2 pivotal trial. Among 158 patients who underwent thoracic endovascular aortic repair (TEVAR) between March 2004 and July 2006, 64 received a 1-component stent-graft (group 1) and 94 patients a 2-component device (group 2). In group 2, there were more men (79% vs. 63%; p = 0.03), and the patients had more diagnosed (p<0.01) and previously repaired (p<0.01) abdominal aortic aneurysms. Aneurysms in group 2 were significantly larger in both diameter (63 vs. 56 mm, p<0.01) and length (157 vs. 113 mm, p<0.01). Percent of thoracic aorta covered by the stent-graft was greater in group 2 (80% vs. 50%, p<0.01). Patients in group 2 had a significantly longer operation time (124±48 vs. 100±39 minutes, p<0.01) and significantly increased estimated blood loss during the procedure (248±359 vs. 169±139 mL, p = 0.05). Procedural success at 30 days was 95% in group 1 and 85% in group 2 (p = 0.06). Postoperative paraplegia and paraparesis were not observed in group 1, but 9 patients in group 2 (p = 0.01) were affected. Treatment success, endoleak, migration, secondary intervention rate, and all-cause and aneurysm-related mortality were not significantly different between the groups at 30 days, 1 year, and 2 years. TEVAR using 1 or 2 TX2 components has similar results in terms of mortality and midterm treatment success. Patients treated with 2 components showed increased perioperative morbidity, including paraplegia, which may be related to the greater extent of graft coverage required in this patient group, as well as to male gender, previous aortic repair, longer operating time, and increased blood loss.

Gender analysis of the pivotal results of the Medtronic Talent Thoracic Stent Graft System (VALOR) trial

This study evaluated the differences between male and female patients undergoing thoracic endovascular aneurysm repair (TEVAR) in a pivotal Food and Drug Administration (FDA)-approved trial. The Evaluation of the Medtronic Vascular Talent Thoracic Stent Graft System for the Treatment of Thoracic Aortic Aneurysms (VALOR) study was a prospective, nonrandomized, multicenter, pivotal trial conducted in the United States. Patients were enrolled between December 2003 and June 2005. Follow-up was conducted at 30 and 365 days. VALOR enrolled 115 men (58.9%; 69.3 ± 11.7 years old), and 80 women (41.1%; 71.6 ± 10.1 years old). Iliac conduits were used more often in women, who had smaller diameter external iliac arteries, than in men (38.8% vs 8.8%, P < .001). Women required more blood transfusions and had a longer hospital length of stay. At 30 days, more major adverse events occurred in women than in men (52.5% vs 33.0%, P = .008), with more vascular access-related and respiratory complications. No gender-based differences were seen in all-cause mortality or in aneurysm-related death. The composite end point of 365-day "successful aneurysm treatment," defined as no aneurysm growth >5 mm at the 365-day follow-up visit compared with the 30-day follow-up visit and absence of any type I endoleak requiring a secondary procedure, favored women over men (98.2% vs 82.4%, P = .004). TEVAR with the Talent device provided similar rates of 365-day mortality and morbidity for men and women. Although female patients had higher rates of periprocedural complications, they also more often had successful aneurysm treatment at the 1-year follow-up.

Transcranial Doppler findings during thoracic endovascular aortic repair

Thoracic endograft placement has become an acceptable treatment alternative to open repair of the thoracic aorta. Cerebral embolization when manipulating the aortic arch during cardiac catheterization is well described, but the influence of thoracic endovascular aortic repair (TEVAR) on this event remains poorly studied. Our aim was to quantify the number of microembolic signals (MES) detected by transcranial Doppler (TCD) during different stages of TEVAR and correlate them with landing zones, subclavian revascularization, and postoperative morbidity and mortality. TCD was used to monitor 20 patients during TEVAR for the treatment of thoracic aortic aneurysms (TAAs) in 17 (85%) patients, followed by three (15%) with chronic type B aortic dissection and one (5%) Crawford type I thoracoabdominal aortic aneurysm (TAAA). Imaging and medical parameters were entered into a combined database. TCD signals were recorded digitally for the entire case. MES, velocities, and pulsatility index values were entered into a combined database. The total number of MES calculated for the diagnostic phase before TEVAR placement and during the treatment phase for all cases combined was 1081 and 1141, respectively. The highest MES counts were generated by the pigtail catheter placement during the diagnostic phase and by device placement during the treatment phase. Embolic count to right/left sides was equal overall. In the diagnostic phase, an average of nine MES were seen right/left, whereas during the treatment phase, 45 and 43 MES were seen, respectively, for right/left. A significant association was found between the total number of MES and postoperative stroke, transient ischemic attack (P = .0055), and death (P = .0053). TCD can detect microemboli during TEVAR and is able to identify the procedural aspects most associated with cerebral microemboli.

Propensity-matched cohort validates findings of the VALOR trial

The Evaluation of the Medtronic Vascular Talent Thoracic Stent Graft System for the Treatment of Thoracic Aortic Aneurysms (VALOR) trial findings noted superior 30-day and 1-year outcomes of the Talent thoracic endograft (Medtronic Vascular, Santa Rosa, Calif) compared with surgical repair of descending thoracic aneurysms (DTAs). Data from 195 prospective thoracic endovascular aneurysm repair (TEVAR) patients treated with the Talent device and 189 retrospective controls undergoing open surgical repair (OSR) from three centers of excellence were included in the trial after completion of TEVAR enrollment and compared. Such comparisons are biased by baseline differences among TEVAR vs OSR, however, propensity score (PS) analysis can reduce bias and validate such comparisons. Logistic regression was used to generate a PS (range, 0-1) to identify baseline characteristics more likely in TEVAR. The PS estimated the probability that any patient would undergo TEVAR (eg, a PS of 0.99 represents a 99% chance a patient belongs to TEVAR). PSs were then generated for all patients, and TEVAR and OSR patients were divided into tertiles based on the PS to reduce up to 80% of inherent bias. Outcomes from the middle tertile (T2), patients equally likely (midrange PS) to be in TEVAR or OSR and therefore best matched, were compared using regression analysis and were also compared with the outcomes in the overall trial group. Correlates of membership in TEVAR were smaller aneurysm (P < .001), anticoagulants (P < .01), no previous abdominal aortic aneurysm (AAA) repair (P < .01), no peripheral vascular disease (P = .001), statin use (P = .002), aspirin use (P = .002), older age (P = .028), race (P = .007), male gender (P = .02), and heart failure (P = .035). T2 included 68 TEVAR (PS, 0.58 ± 0.2) and 67 OSR patients (PS, 0.46 ± 0.2). VALOR overall reported differences in aneurysm size (56 mm TEVAR vs 69 mm open) and prior AAA repair (19% TEVAR vs 37% open), and this adjusted to no differences in T2 patients. In the well-matched T2 cohort, TEVAR patients had similar 30-day mortality (0% vs 3% OSR; P = .2) and improved 1-year aneurysm-related mortality rates (0% TEVAR vs 8% OSR; P = .05) compared with the OSR patients. This finding was in concurrence with the VALOR trial reporting similar benefit in TEVAR patients. The all-cause 1-year mortality showed a favorable trend for TEVAR in the VALOR trial; however, in T2 patients, 1-year all-cause mortality was similar in both groups of patients (17% TEVAR vs 15% OSR; P = .8). Age (P = .01), history of cerebrovascular accident (P < .05), antiarrhythmia medication (P = .04), and renal disease (P < .03) independently predicted all-cause and aneurysm-related mortality by regression analysis. PS analysis is an important tool for elimination of bias inherent when retrospective controls are used. Its application to VALOR validates the long-term benefit in aneurysm-related mortality conferred by TEVAR in patients undergoing endovascular DTA repair.

胸部大動脈瘤に対するＭａｔｓｕｉ‐Ｋｉｔａｍｕｒａ（ＭＫ）ｓｔｅｎｔによるｏｐｅｎ ｓｔｅｎｔ‐ｇｒａｆｔｉｎｇ（ＯＳＧ）の初期成績

Matsui-Kitamura（MK）stentによるopen stent-grafting（OSG）の初期成績を検討したので報告する．2005年8月から2011年3月までに胸部大動脈瘤（TAA）35例（男女比29/6，年齢58～86歳，平均71歳）に対し本術式を施行した．瘤形態は真性29例，解離4例（A/B 1/3），真性＋B型解離2例であった．破裂有無は，破裂ないし切迫破裂4例，未破裂31例，瘤径は45～100 mm，平均67 mmであった．ステントグラフト径は33.5±3.2 mm，挿入長は149±21 mm，末梢位置はTh 6：2例，Th 7：11例，Th 8：15例，Th9：6例，Th 12：1例であり，全例挿入留置に成功した．併用手術は，MVRおよびCABG各1例，ペースメーカー植え込み術2例であった．術後合併症は，72時間以上人工呼吸10例（28.6%），Stroke 2例（5.7%），対麻痺1例（2.9%），不全対麻痺4例（11.4%，うち3例は一過性で完全回復），出血再開胸・虚血性腸炎・急性腎不全による一過性血液透析・気管切開を各1例認めた．病院死亡3例（8.6%，呼吸不全・腸管壊死・脳幹梗塞各1例）に認めた．われわれの開発したMK stentによるOSGは，ほぼ満足いく初期成績であり，その有効性が示唆された．

Practice Patterns for Thoracic Aneurysms in the Stent Graft Era: Health Care System Implications

The US Food and Drug Administration approved the first thoracic aneurysm endograft in 2005. However, because the United States lacks a thoracic aneurysm endovascular repair registry, implications of Food and Drug Administration endograft approval on surgical management of thoracic aneurysms in clinical practice are unknown. Retrospective review of thoracic aneurysm repair rates for 2000 to 2007 and analysis of patient characteristics and complications for 2006 and 2007 cohorts uses the National Inpatient Sample. International Classification of Diseases, 9th Revision codes were used to identify unruptured descending thoracic aneurysm cases undergoing either thoracic endovascular aortic repair (39.73) or open repair (38.45). Thoracic aneurysm open repair averaged 3.3 per million from 2000 to 2002 and increased to 5.6 per million in 2003 with introduction of 16 slice computed tomographic scanners. In 2005 endovascular repair was 1.2 repairs per million, which increased dramatically to 6.1 repairs per million in 2006. In 2007, endovascular repair decreased to 4.8 repairs per million while the open repair rate was 3.1 repairs per million. The 2006 and 2007 open repair cohorts had more favorable baseline characteristics compared with the endovascular cohort. Open repair mortality was significantly greater than endovascular mortality in 2006 (estimated relative risk, 8.48; 95% confidence interval 3.03 to 23.75), but not in 2007 (estimated relative risk, 0.71; 95% confidence interval 0.12 to 4.24). Length of stay was greater for open repair in 2006 and 2007. Thoracic endovascular aortic repair has been rapidly adopted in the United States resulting in increased treatment of thoracic aortic aneurysms. Despite older age and comorbidities, endovascular repair had better outcomes and shorter hospital stays.

Ruptured Thoracic Aneurysms

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 …

Thoraco-abdominal aortic conventional surgery in elderly population

BackgroundThoraco-abdominal aortic pathologies are universallyconsidered as lethal conditions. The most prevalentetiology is atherosclerotic or degenerative but otheretiologies such as mycotic, post-traumatic, connectivetissue disease-related and dissection-related are alsoencountered. The estimated actuarial 1-year and 5-yearsurvival rates in patients with thoraco-abdominal aorticaneurysm is 60% and 20% respectively in untreatedpatients [1,2]. The prognosis, with or without treatment,is complicated by high incidence of comorbidities and isstrictly related with a predominantly elderly population.Since the early ’90s many Authors have investigated theefficacy of endovascular treatment in the treatment ofthoracic and thoraco-abdominal aortic aneurysms and/or complicated aortic dissections. On this basis webelieve that conventional surgery may be reserved alsoin patients over 70 years-old in absence of severepreoperative comorbidities such as chronic obstructivepulmonary disease, renal insufficiency, coronary arterydisease, cerebral vasculopathy.Our surgical approach involves graft replacementbetween the distal aortic arch and the descending thor-acic aorta through a left posterolateral thoracotomy pre-paring proximal and distal aortic cuffs using biologicalglues and external strips of Teflon felt to reinforce thewall. Moreover cerebrospinal fluid drainage by acatheter inserted at the level of L3 or L4 to maintain apressure of 10 mmHg or below and perfusion of thedistal aorta using femoro-femoral bypass is performed.All patients are positioned on the operating table in thelateral position with the abdomen and the pelvis turnedso that the groin was at a 45 angle to the table to allowcannulation of the femoral vessels.In a preliminary study comparing endovascular andconventional surgery treatments in patients with acutetype B aortic dissection, the early results regarding hos-pital mortality and postoperative complications are infavour of endovascular management but no significantdifferences are found in terms of survival at 1, 3 and8 years.ConclusionsConventional surgery in the treatment of thoracic andthoraco-abdominal aortic pathologies also in elderlypopulation may be considered an effective procedure inthe era of stent graft. The aim of further randomizedstudies study is to demonstrate the real superiority ofendovascular procedure over open surgery and to defineits role in the treatment of aortic pathologies especiallyin terms of mid and long-term follow-up.

Thoracic Aortic Aneurysms and Dissections: Endovascular Treatment

The treatment of thoracic aortic disease has changed radically with the advances made in endovascular therapy since the concept of thoracic endovascular aortic repair was first described 15 years ago. Currently, there is a diverse array of endografts that are commercially available to treat the thoracic aorta. Multiple studies, including industry-sponsored and single-institution reports, have demonstrated excellent outcomes of thoracic endovascular aortic repair for the treatment of thoracic aortic aneurysms, with less reported perioperative morbidity and mortality in comparison with conventional open repair. Additionally, similar outcomes have been demonstrated for the treatment of type B dissections. However, the technology remains relatively novel, and larger studies with longer term outcomes are necessary to more fully evaluate the role of endovascular therapy for the treatment of thoracic aortic disease. This review examines the currently available thoracic endografts, preoperative planning for thoracic endovascular aortic repair, and outcomes of thoracic endovascular aortic repair for the treatment of both thoracic aortic aneurysms and type B aortic dissections. Mt Sinai J Med 77:256-269, 2010. (c) 2010 Mount Sinai School of Medicine.

Endovascular treatment of thoracic aortic aneurysm and dissection: expanding indications

With more experience of the technique, it is becoming increasingly evident that more and more patients with pathology of the thoracic aorta can be treated by endovascular techniques. The published evidence for many indications shows that thoracic aortic endografting has clear advantages in terms of reduced mortality and morbidity, and shorter hospital stay compared with open surgery. These favourable outcomes have inspired interventionalists to try these endovascular methods in patients with more complex pathology, such as lesions involving the aortic arch and the thoracoabdominal segment. The indications for thoracic endografting have been expanded in the last few years (Figure 1). The following account describes briefly the management approach for patients with descending thoracic aneurysms, aortic arch aneurysms, and thoracoabdominal aneurysms.

Endovascular stent-grafting of anastomotic pseudoaneurysms following thoracic aortic surgery

Anastomotic pseudoaneurysm is a rare but life-threatening complication after thoracic aortic surgery. Endovascular stent-grafting is a less invasive treatment for thoracic aortic aneurysm; however, its clinical usefulness for anastomotic pseudoaneurysms following thoracic aortic surgery is unclear. A series of 12 anastomotic pseudoaneurysms in 10 patients, which occurred following thoracic aortic surgery, underwent endovascular stent-grafting in our university hospital. Eight emergent endovascular stent-grafting cases were included in this study. A hand-made stent-graft, reconstructed by suturing graft material to an endoskeleton of modified Gianturco Z stents, was used in all cases. The delivery success rate was 91.7%, and the hospital mortality rate was 25.0%. Two cases were converted to open surgery during the postoperative phase because of a type I endoleak. Complete absorption or shrinkage of the anastomotic pseudoaneurysm was observed in seven of nine cases. Endovascular stent-grafting for patients with anastomotic pseudoaneurysms of the thoracic aorta following thoracic aortic surgery has become a possible optimal treatment. However, long-term outcome remains unclear, and periodical follow-up is required.

Endovascular Repair of Combined Distal Arch and Extent in Thoracoabdominal Aneurysm: Landing Zone Extension into the Aortic Arch and Mesenteric Portion of the Abdominal Aorta

Thoracic endovascular aortic repair (TEVAR) has emerged as a surgical alternative for patients at prohibitive risk for open repair. We report a series of patients at a single institution with type I thoracoabdominal aneurysms (TAAAs) who required coverage of the left subclavian (LSA) and celiac artery to achieve aneurysmal exclusion during TEVAR. Between August 2005 and April 2009, 219 patients underwent TEVAR. Patients with type I TAAAs requiring coverage of the LSA (zone 2) and celiac artery to achieve adequate proximal and distal fixation were identified. Except when contraindicated by renal failure, all patients underwent preoperative computed tomography angiography (CTA) to evaluate collateral circulation between the celiac and superior mesenteric artery (SMA). Six of 219 (2.7%) patients undergoing TEVAR had type I TAAAs that required proximal landing zone extension to zone 2 of the aortic arch and distal landing zone extension into the mesenteric abdominal aorta to include coverage of the celiac artery. There were two male and four female patients, and the mean age was 78.3 years (range, 68 to 83 years). The average maximum aneurysmal diameter was 6.8 cm. All six patients underwent elective LSA bypass prior to TEVAR with subsequent coil embolization of the LSA remnant during TEVAR. In a mean follow-up of 21.2 months, there were no reported complications of paraplegia, stroke, endoleak, visceral ischemia, spinal ischemia, conversion to open revascularization, left upper extremity ischemia, or aneurysm rupture. Although TEVAR has evolved into a viable option in the treatment of thoracic aortic aneurysms, there is little data to support distal landing zone extension into the abdominal aorta, and there are no reported series of TEVAR for type I TAAAs. This preliminary series suggests that TEVAR can be utilized in the treatment of type I TAAAs, and that coverage of the LSA and celiac artery to achieve aneurysmal exclusion is safe and viable in select patients. Elective LSA revascularization and subsequent coil embolization are useful adjuncts to reduce the risk of paraplegia and endoleak and to maintain left upper extremity perfusion. Preoperative CTA and intraoperative angiography are essential to confirm SMA to celiac collateralization prior to complete celiac interruption.TableTEVAR landing zone extension into the aortic arch and abdominal aorta: Collateral assessmentCeliac coveragePatient #Preoperative CTA findingsIntraoperative angiography: predeploymentIntraoperative angiography: postdeploymentPartial1Noncontrast CTAortogramPatent SMA, celiac2Replaced R hepatic arteryAortogramPatent SMA, celiacComplete1Collaterals poorly visualizedSelective SMA AngiogramSMA to celiac collaterals2Pancreaticoduodenal collaterals visualizedAortogramSMA to celiac collaterals3Chronic celiac occlusionAortogramSMA to celiac collaterals4Replaced R hepatic arteryAortogramPatent SMA, R hepaticCT, Computed tomography; CTA, computed tomography angiography; R, right; SMA, superior mesenteric artery. Open table in a new tab

TCT-55: Midterm Outcome of Inoue Stent Graft for the Treatment of Thoracic Aortic Aneurysm and Dissections

TCT-55: Midterm Outcome of Inoue Stent Graft for the Treatment of Thoracic Aortic Aneurysm and Dissections

Standard of Practice for the Endovascular Treatment of Thoracic Aortic Aneurysms and Type B Dissections

Thoracic endovascular aortic repair (TEVAR) represents a minimally invasive technique alternative to conventional open surgical reconstruction for the treatment of thoracic aortic pathologies. Rapid advances in endovascular technology and procedural breakthroughs have contributed to a dramatic transformation of the entire field of thoracic aortic surgery. TEVAR procedures can be challenging and, at times, extraordinarily difficult. They require seasoned endovascular experience and refined skills. Of all endovascular procedures, meticulous assessment of anatomy and preoperative procedure planning are absolutely paramount to produce optimal outcomes. These guidelines are intended for use in quality-improvement programs that assess the standard of care expected from all physicians who perform TEVAR procedures.

Favorable Early Outcomes for Patients with Extended Indications for Thoracic Endografting

Endografts originally designed and approved for the treatment of thoracic aortic aneurysms have rapidly been adopted for nonapproved use in the treatment of disorders of the thoracic aorta, including aortic transection, dissection, pseudoaneurysms, and thoracoabdominal aneurysms. The purpose of this study was to evaluate the early outcomes of patients treated with thoracic endografts for nonapproved indications at our institution. The medical records of patients undergoing thoracic endografting at our institution from August 2005 until March 2008 were reviewed. Patients undergoing endografting for uncomplicated thoracic aortic aneurysms were excluded. The outcomes of patients with extended indications for thoracic endografting were studied. During the study period, endografting was performed in 31 patients for nonapproved aortic conditions. Patients underwent endografting for a spectrum of indications, including aortic transection (n = 12), complications of type B aortic dissection including rupture (n = 9), thoracoabdominal aneurysm with visceral debranching (n = 6), aortic arch debranching (n = 2), and pseudoaneurysm associated with prior coarctation repair (n = 2). Early outcomes were favorable. All patients had successful endograft repair of their anatomic lesion. There were no endoleaks. There was no hospital mortality. Average hospitalization was 15 days for patients with aortic transection and 9 days for all other patients. Thoracic endografts are versatile devices that with appropriate expertise can be used effectively to treat a spectrum of disorders of the thoracic aorta, including acute emergencies. Early outcomes of patients with extended indications for thoracic endografting compare favorably to published series of patients treated with open procedures. Further study is required to assess the long-term efficacy of these devices.

Endovascular and Conventional Treatment of Thoracic Aortic Aneurysms: A Comparison of Costs

The purpose of this study is to compare costs of conventional surgical therapy with costs of endovascular stent-graft placement in patients with thoracic aortic aneurysms. Fifteen patients undergoing either conventional surgical therapy or endovascular stent-graft placement of thoracic aortic aneurysms were analyzed. A catalog of costs was then created for both procedures and this catalog was applied individually to each patient. Total costs of the service provision of endovascular stent-graft placement including anesthesia were 38.220.98 euros considering 1.7 stent-grafts per patient and including 5900.00 euros (Euros) for days of care. In conventional surgical therapy, adding the costs of the service provision of left heart catheterization, conventional surgical therapy including anesthesia, as well as intraoperative echocardiography a sum of 19.534.12 euros was calculated. Days of care accounted for 31.230.00 euros and total costs of 50.764.12 euros were calculated. The difference between total costs of the two procedures was 12.543.14 euros. Costs of endovascular stent-graft placement in patients with thoracic aortic aneurysms compare favorably with conventional surgical therapy, revealing a cost benefit of 24.7%. Higher procedural costs are outweighed by a lower number of days of care. Nevertheless, aneurysm-related secondary endovascular or surgical procedures may balance the benefit of endovascular therapy. Which strategy to choose, conventional or endovascular, should remain to be based on age, comorbidity, and technical feasibility.

Alternative Approach for Endovascular Treatment of Aortic Aneurysms

Endovascular treatment of thoracic aortic aneurysms is limited in patients with small or calcified femoral arteries, with the most serious complication being rupture at the insertion site or distal sections of the artery. To overcome this, an iliac conduit is normally created by surgical exposure. We used an original access in a patient with a thoracoabdominal aortic aneurysm and narrow femoral artery to introduce the endovascular prosthesis directly into the surgically exposed iliac artery by a small laparotomy and abdominal wall tunnel without iliac conduit. The endoprosthesis was easily implanted, and complete hemostasis was achieved with minimal blood loss.

Endograft Collapse After Thoracic Stent-Graft Repair for Traumatic Rupture

Endovascular stent grafting has emerged as a new strategy for repair of traumatic aortic disruptions; however, this technique is not without complications. In this report, we describe a case of endograft collapse after a traumatic aortic rupture.

Development of an In Vitro Porcine Aorta Model to Study the Stability of Stent Grafts in Motor Vehicle Accidents

Endovascular stent grafts for the treatment of thoracic aortic aneurysms have become increasingly utilized and yet their locational stability in moderate chest trauma is unknown. A high speed impact system was developed to study the stability of aortic endovascular stent grafts in vitro. A straight segment of porcine descending aorta with stent graft was constrained in a custom-made transparent urethane casing. The specimen was tested in a novel impact system at an anterior inclination of 45 deg and an average deceleration of 55 G, which represented a frontal automobile crash. Due to the shock of the impact, which was shown to be below the threshold of aortic injury, the stent graft moved 0.6 mm longitudinally. This result was repeatable. The presented experimental model may be helpful in developing future grafts to withstand moderate shocks experienced in motor vehicle accidents or other dynamic loadings of the chest.

Treatment of Delayed Retrograde Dissection after Endovascular Stenting of Thoracoabdominal Aortic Aneurysm: Graft-to-Endograft Anastomosis

Endovascular treatment of thoracic aortic aneurysms may be associated with procedure-related early and late complications. We describe the case of a 70-year-old man who developed acute retrograde dissection of the ascending aorta 30 days after endovascular stent grafting of a thoracoabdominal aortic aneurysm and prior revascularization of the left subclavian artery. The ascending aorta and aortic arch were successfully replaced with a Dacron graft; the distal part of the graft was partially anastomosed to the previously placed endograft. Surgical repair of dissections following a thoracic endovascular procedure is reliable with a graft-to-endograft anastomosis when native aortic tissue is not suitable.