Endovascular treatment of thoracoabdominal aortic aneurysms

Open surgical repair of thoracoabdominal aortic aneurysms (TAAA) bridges the aneurysm with a large, conventional, unstented graft and restores flow to the visceral arteries through short grafts or direct sutured connections between the visceral arterial orifices and the primary conduit. The combination of retrograde visceral bypass and endovascular aneurysm exclusion substitutes an endovascular stent-graft for a standard graft, stented overlaps for sutured anastomoses, and transluminal insertion for direct aortic exposure. Compared to open surgery, the combination treatment requires less dissection, and causes less hemodynamic instability, and lower complication rates, particularly paraplegia. The multi-branched stent-graft substitutes endovascular visceral bypass through branches of the stent-graft for surgical visceral bypass through branches of a conventional extraluminal graft, which has the potential to further reduce surgical dissection, hemodynamic instability, and complication rates. We favor a modular approach in which short, axially oriented cuffs are extended into the visceral arteries, using self-expanding covered stents. In the past year, we have used this approach to implant multi-branched thoracoabdominal stent-graft in 16 patients. In our opinion, this approach will eventually assume a prominent role in the management of TAAA.