Endovascular devices for thoracic aortic repair
- Ronald M Fairman, MD
Ronald M Fairman, MD
- Professor of Surgery and Radiology
- University of Pennsylvania School of Medicine
- Rabih A Chaer, MD
Rabih A Chaer, MD
- Professor of Surgery
- The University of Pittsburgh School of Medicine
- Section Editors
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Sciences Center - Dallas Campus
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
Thoracic endovascular aortic repair (TEVAR) is becoming increasingly popular due to reduced perioperative morbidity and mortality compared with open surgical repair . Although TEVAR was developed for the treatment of degenerative aneurysmal disease, other pathologies can be treated using these devices including aortic dissection, aortic transection, intramural hematoma and penetrating aortic ulcer [1,2]. Endovascular aortic repair requires that specific anatomic criteria be fulfilled, and, for those with appropriate anatomy, this technique allows the treatment of patients who might not otherwise be candidates for aortic repair. Advanced endovascular aortic devices that allow flow into specific aortic branches depending upon the level of repair (eg, innominate, left subclavian, renal artery, internal iliac artery) are available to treat more complex anatomy.
The placement of aortic endografts is associated with device-related complications that can include component disconnection, stent-graft buckling and migration over time often due to disease progression (eg, aortic dissection). In the thoracic aorta, secondary intervention is needed in 10 to 60 percent of patients, more commonly in patients undergoing endovascular repair of thoracic dissection and more complicated hybrid repairs [3-5]. As such, these devices require lifelong surveillance; the long-term outcomes continue to be studied.
The specific devices available for endovascular repair of the thoracic aorta will be reviewed here. The indications for, placement of, and complications of these devices are discussed elsewhere. (See "Endovascular repair of the thoracic aorta" and "Complications of endovascular abdominal aortic repair".)
The aorta is the major arterial conduit conveying blood from the heart to the systemic circulation. It originates immediately beyond the aortic valve ascending initially. Then it curves forming the aortic arch, and descends caudally adjacent the spine. The ascending thoracic aorta gives off the coronary arteries. The aortic arch branches are typically the brachiocephalic trunk (branches to the right common carotid and right subclavian arteries), left common carotid and left subclavian arteries; however, aortic arch anatomy is variable (figure 1).
The descending thoracic aorta provides paired thoracic arteries (T1-T12) and continues through the hiatus of the diaphragm to become the abdominal aorta which extends retroperitoneally to its bifurcation into the common iliac arteries at the level of the fourth lumbar vertebra (figure 2). The abdominal aorta lies slightly left of the midline to accommodate the inferior vena cava which is in close apposition. The branches of the aorta (superior to inferior) include the left and right inferior phrenic arteries, left and right middle suprarenal arteries, the celiac axis, superior mesenteric artery, left and right renal arteries, left and right internal spermatic arteries, inferior mesenteric artery, left and right common iliac artery, middle sacral artery and the paired lumbar arteries (L1-L4).
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- AORTIC ANATOMY
- BASIC PRINCIPLES
- Delivery system
- Main device
- THORACIC DEVICES
- TAG and CTAG
- TX2 and Alpha
- Valiant Thoracic Stent-Graft System
- Investigational and withdrawn devices
- - TAArget
- - E-Vita
- - Streamliner Multilayer Flow Modulator
- - Withdrawn - Talent Thoracic Stent-Graft System
- TEVAR TRIALS
- ADVANCED DEVICES
- Fenestrated grafts
- Branched grafts
- CHOICE OF DEVICE
- SUMMARY AND RECOMMENDATIONS