Endovascular repair of lesions involving the descending thoracic aorta

Vascular lesions involving the thoracic aorta are often life-threatening conditions that carry significant morbidity and mortality with traditional open surgical repair. Preliminary results suggest that endovascular therapy is an effective and possibly advantageous treatment for diseases of the descending thoracic aorta.

Between October 2000 and May 2004, 50 consecutive patients underwent endovascular stent-grafting of lesions involving the descending thoracic aorta. Attempted stent-graft deployment was performed electively in 39 patients and emergently in 11. The pathology of electively treated aortic lesions included degenerative/atherosclerotic aneurysms (n = 24), pseudoaneurysms (n = 11), aortic dissections (n = 2), and penetrating ulcers (n = 2). Emergently treated aortic lesions were for acute rupture due to infectious (mycotic) aneurysms (n = 4), atherosclerotic/degenerative aneurysms (n = 3), acute type B dissections (n = 2), and acute transections (n = 2). Devices used include Talent (n = 45), AneuRx aortic cuffs (n = 2), custom-fabricated Gianturco-Dacron grafts (n = 2), and a modified Cook-Zenith abdominal aortic graft (n = 1). Follow-up was performed at 1-month, 6-months, 1-year, and annually thereafter.

Primary technical success, defined as successful deployment and exclusion of the lesion without evidence of type I or type III endoleak, was achieved in 48 (96%) of 50 patients. In one patient, the procedure was terminated due to inability to access the iliac vessels. In another patient, a type III endoleak was observed at the completion of the primary procedure that required deployment of an additional stent-graft component 2 months later. Of the 49 patients who received endografts, seven underwent secondary procedures to correct endoleaks, with five of these seven requiring the deployment of additional endovascular stent-graft components. Major complications included four in-hospital deaths, with three of these occurring in patients treated emergently. Additionally, respiratory failure (n = 6), multisystem organ failure (n = 2), cerebrovascular accident (n = 2), retroperitoneal hematoma (n = 2), acute renal insufficiency (n = 1), and pulmonary embolus (n = 1) were also observed. The overall endoleak rate was 20%, with five primary (< or = 30 days) and five secondary (> 30 days) endoleaks observed. Five of the endoleaks were treated with the deployment of one or more additional endovascular stent-graft components. Two of the endoleaks were treated with endovascular balloon remolding. Mean follow-up was 271 days. There were no aneurysm ruptures or aneurysm-related deaths.

Endovascular treatment of vascular lesions involving the descending thoracic aorta can be safely performed with low morbidity in high-risk patients. Endovascular repair may become an attractive alternative for the treatment of a wide range of pathology along this vascular territory.