Evolving experience with thoracic aortic stent graft repair

We reviewed our initial thoracic aorta (TA) stent graft experience in 28 patients from the perspective of treatment with homemade devices (Dacron over Gianturco Z stents; 14 cases) and a commercial device (Excluder; W.L. Gore Co, Flagstaff, Ariz; 14 cases).

From November 1996 to August 2001, 28 patients with a spectrum of disease (degenerative aneurysm, n = 18; chronic dissection, n = 4; pseudoaneurysm, n = 3, with 1 trauma and 2 anastomotic; intramural hematoma, n = 2; and coarctation, n = 1) underwent TA stent grafting. Clinical parameters included a mean age of 71 years, 12 female (43%) and 16 male (57%) patients, 14 of 28 patients (50%) with major comorbidities that prohibited open repair, and nine of 28 patients (32%) with urgent or ruptured conditions. Seven patients (25%) needed open surgical access to the aorta or iliac artery for either concomitant abdominal aortic aneurysm repair (n = 3) or device deployment (n = 4), and six of 28 patients (21%) needed left subclavian-carotid transposition to provide for an adequate proximal fixation site. Focal (<15 cm) grafts were used in 19 patients, and the remaining patients had at least two thirds of their descending aorta excluded.

The procedural mortality rate was 3.5% (1/28 patients); three additional deaths, (1 device-related) occurred during the mean follow-up period of 17 months. Access artery complications occurred in six of 28 patients (21%), with one fatal. No immediate or late open conversions were performed. One patient needed urgent dilation and stenting of a collapsed stent graft 3 weeks after deployment. Serious systemic complications included temporary dialysis (n = 1), congestive heart failure (n = 1), and unstable angina (n = 1). Complete exclusion of the TA lesion was noted in 27 of 28 cases (96%). No cases of spinal cord ischemia were noted. Ease and accuracy of deployment was superior for the second generation (commercial) device.

TA stent graft repair, although in evolution, appears to be a safe and effective alternative to open repair for many patients with a spectrum of TA disease. Prospective trials for individual diseases will be necessary to define its ultimate role.