Endovascular treatment of thoracic aortic aneurysms

Descending thoracic aortic aneurysms (TAA) and chronic dissections have high morbidity and mortality rates. For 10 years, the evolution of both imaging techniques and aortic stent-graft design has brought a new therapeutic hope for patients at high risk for surgery presenting non-ruptured or emergency cases of TAA. Our goal is to describe the endovascular technique, review its state of the art and compare its mid-term results to those of conventional surgery. We also describe surgical ways to manage complex TAA, involving the aortic arch and/or the celiac aorta, as therapeutic solutions for high risk patients for surgery with unfitted anatomy for endovascular repair. After a review of the literature dealing with the natural history, the etiology, and the surgical treatment, we describe the endovascular devices, the conventional stent-grafting technique and we detail the adjunctive procedures we used to manage complex cases. We then retrospectively report our personal 38-patient experience from October 1999 to February 2003. Thirty-three patients presented with TAA and the average age was 70 years old (35-88), while the male/female ratio was 5.3. All of them were at high risk for surgery, of which 27% required adjunctive procedures to achieve proximal and/or distal neck management. The in-hospital death rate was 9%. We reported no case of paraplegia and only 1 patient with post-operative regressive stroke (3%). All the aneurysmal sacs were successfully excluded without early endoleak. During follow-up period (mean: 2 years; 1-40 months), we observed a late death rate of 10%. All aneurysmal sac remained excluded by the endografts and no stent-graft migration was observed. No late endoleak appeared during the follow-up course, but 1 patient presented a proximal aortic enlargement, which required total transposition of the supra-aortic vessels and stent-graft extension. The endovascular repair of TAA and chronic dissections proved to be feasible and offers hopeful mid-term

With a very low morbidity-mortality rate, compared to surgery, the endovascular technique may represent an unquestionable therapeutic options, especially for patients at high risk for surgery. However, long-term results are needed to point out the durability of descending thoracic aortic stent-grafting. Neck management must be encouraged in order to avoid type 1 endoleaks in cases with short landing zones.