Expert Consensus Document on the Treatment of Descending Thoracic Aortic Disease Using Endovascular Stent-Grafts

doi:10.1016/j.athoracsur.2007.10.099

The Annals of Thoracic Surgery

Volume 85, Issue 1, Supplement, January 2008, Pages S1-S41

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https://doi.org/10.1016/j.athoracsur.2007.10.099 Get rights and content

Between 43,000 and 47,000 people die annually in the United States from diseases of the aorta and its branches and continues to increase. For the thoracic aorta, these diseases are increasingly treated by stent-grafting. No prospective randomized study exists comparing stent-grafting and open surgical treatment, including for disease subgroups. Currently, one stent-graft device is approved by the Food and Drug Administration for descending thoracic aortic aneurysms although two new devices are expected to obtain FDA approval in 2008. Stent-graft devices are used “off label” or under physician Investigational Device Exemption studies for other indications such as traumatic rupture of the aorta and aortic dissection. Early first-generation devices suffered from problems such as stroke with insertion, ascending aortic dissection or aortic penetration from struts, vascular injury, graft collapse, endovascular leaks, graft material failure, continued aneurysm expansion or rupture, and migration or kinking; however, the newer iterations coming to market have been considerably improved. Although the devices have been tested in pulse duplicators out to 10 years, long-term durability is not known, particularly in young patients. The long-term consequences of repeated computed tomography scans for checking device integrity and positioning on the risk of irradiation-induced cancer remains of concern in young patients. This document (1) reviews the natural history of aortic disease, indications for repair, outcomes after conventional open surgery, currently available devices, and insights from outcomes of randomized studies using stent-grafts for abdominal aortic aneurysm surgery, the latter having been treated for a longer time by stent-grafts; and (2) offers suggestions for treatment.

Section snippets

Natural History of Descending Thoracic Aortic Aneurysms

John A. Elefteriades, MD, Eric E. Roselli, MD, Richard J. Shemin, MD, and Thoralf M. Sundt III, MD

To determine appropriate criteria for surgical intervention and type of surgical therapy, it is important to understand the natural history of untreated aneurysmal thoracic aorta. For the descending thoracic aorta, a significant aneurysmal dilatation is usually defined as an aorta twice the diameter of the patient's contiguous normal aortic caliber. Thus, in an average-height older man with an

Growth Rate of Aortic Aneurysms

In adults, the normal aorta grows very slowly. Published reports note that in older populations, the ascending aorta grows at a rate of about 0.07 cm per year and the descending and thoracoabdominal aorta at a rate of about 0.19 cm per year [4]. Thus, when aneurysmal disease is present, growth of the aneurysm tends to follow an indolent course. Indeed, many reports of rapid growth of aneurysms in individual patients are related to measurement errors; that is, they either compare nonidentical

Contemporary Results of Open Surgical Graft Replacement of the Thoracic Aorta

Nicholas T. Kouchoukos, MD, Bruce W. Lytle, MD, Lars G. Svensson, MD, PhD, Hazim J. Safi, MD, and Joseph S. Coselli, MD

Because there are no prospective, randomized studies comparing outcomes of patients treated with open versus endovascular procedures, results of open operations based on reports from single centers and nonrandomized comparisons from Investigational Device Exemption (IDE) studies of open versus endovascular stent-graft procedures provide the only useful information (this is

Indications for Operative Intervention

Lars G. Svensson, MD, PhD

Criteria for operative intervention in asymptomatic patients with aneurysms of the descending thoracic aorta can be categorized according to either size or etiology of the aneurysm. In individual patients, presence of comorbid conditions also must be carefully considered for both open and endovascular procedures. No level A or B scientific evidence from prospective, randomized studies exists related to the timing of operative intervention according to aneurysm size, as

Penetrating Aortic Ulcers

D. Craig Miller, MD

The Stanford group realized early on that the most suitable pathologic target for successful thoracic aortic stent-grafting was lesions that were relatively localized, including penetrating aortic ulcers (PAU), anastomotic pseudoaneurysms, mycotic aneurysms, and false aneurysms due to chronic aortic transections. In most of these pathologic situations, relatively normal aortic necks exist on either side of the lesion that can be used as landing zones for stent-grafts.

Between

The Gore TAG Thoracic Endograft

R. Scott Mitchell, MD

The W.L. Gore TAG thoracic nitinol endograft was presented to a Food and Drug Administration panel in January 2005 and received approval in March 2005, making it the first commercially available thoracic endograft in the United States. An important unique feature of the Gore stent-graft system is that deployment requires passage of only a guidewire above the level of the diaphragm, meaning that the sheath/dilator assemblies inherent in the older stent-graft devices, which

Abdominal Aortic Aneurysm Treatment

Michael A. Curi, MD, MPA, and Gregorio A. Sicard, MD

With the exception of the INSTEAD trial, no prospective randomized studies have compared the natural history of descending thoracic disease with either open surgery or stent-graft treatment, nor have any compared open surgery and stent-grafting. Thus, an examination of published randomized studies on infrarenal aneurysmal disease is informative to the discussion of the best treatment of thoracic aortic disease.

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Most Valuable Application of Thoracic Endovascular Aortic Repair: Acute Complicated Type B Aortic Dissection
2024, Annals of Thoracic Surgery
Single branch arch stent graft combined with laser fenestration in the treatment of a zone two penetrating thoracic aortic ulcer
2023, Journal of Vascular Surgery Cases, Innovations and Techniques
We present the case of a 75-year-old man with a symptomatic penetrating aortic ulcer located in zone 2 on the arch inner curve between the left subclavian artery and left carotid artery treated using a single branch thoracic endovascular aortic repair combined with in situ laser fenestration. The patient underwent a successful procedure with no neurologic impairment and was discharged on the second postoperative day. The postoperative follow-up showed a well-excluded penetrating aortic ulcer.
The efficacy and safety of Gore conformable thoracic stent graft and Valiant Captivia thoracic stent graft for acute type B aortic dissection
2023, International Journal of Cardiology
To evaluate the safety and efficacy of the conformable thoracic aortic endograft (Conformable TAG Thoracic Endoprosthesis [CTAG]; W. L. Gore & Associates, Flagstaff, Ariz) and Valiant Captivia thoracic stent graft (Medtronic Inc., Santa Rosa, CA) for acute type B aortic dissection (TBAD).
The early and mid-term outcomes were analyzed for 413 patients undergoing TEVAR using conformable TAG thoracic endoprosthesis and Valiant Captivia thoracic stent graft for acute TBAD. 100 propensity-matched pairs of patients were generated, including 100 patients in the CTAG group and 200 patients in the Valiant Captivia group.
Operative mortality were 2.33% (3 of 129) in the CTAG group and 1.76% (5 of 284) in the Valiant Captivia group. The median follow-up was 41.67 (26.00–60.67) months. No significant difference in mortality (9 [7.00%] vs. 36 [12.68%], P = 0.95) or re-intervention rate (3 [2.33%] vs. 20 [7.04%], P = 0.29) was observed between two groups. CTAG group have a lower incidence rate of distal stent graft-induced new entry tear than Valiant Captivia group (2.33% vs. 9.86%, P = 0.045). Lower incidence of type Ia endoleak was identified in the CTAG group (2.22%) than the Valiant Captivia group (14.41%) in patients with type III arch (P = 0.039).
Both Valiant Captivia thoracic stent graft and CTAG thoracic endoprosthesis can be safely performed for acute TBAD with low operative mortality, favorable mid-term survival and freedom from reintervention. CTAG thoracic endoprosthesis had fewer dSINE even with larger oversizing and potentially suitable for type III arch with fewer type Ia endoleaks.
Unusual presentation of acute ruptured penetrating aortic ulcer of descending thoracic aorta with right hemothorax
2023, Journal of Vascular Surgery Cases, Innovations and Techniques
Right-sided hemothorax is a rare presentation of ruptured penetrating aortic ulcers. A 72-year-old female presented to the hospital with a penetrating aortic ulcer of the mid-thoracic aorta and a right-sided hemothorax. The patient was taken for thoracic endovascular aortic repair and right-sided tube thoracostomy. The diagnosis was complicated by the patient’s history of pacemaker placement causing prominent venous collaterals in the mediastinum. The postoperative course was complicated by lower extremity weakness, requiring lumbar cerebrospinal fluid drain placement. The patient regained full function of her lower extremities. This case illustrates that patients with ruptured acute aortic syndromes may present with right hemothorax, so index of suspicion should remain high in this population.
Commentary: Thoracic endovascular aortic repair in Marfan syndrome—dancing with dogma
2023, Journal of Thoracic and Cardiovascular Surgery
Midterm outcomes of isolated thoracic aortic replacement in congenital versus degenerative aortopathy in a 15-year institutional cohort
2023, Journal of Vascular Surgery
Open aortic replacement represents the only approved option to address thoracic aortopathy among patients with connective tissue disorders (CTD). The aim of our study was to investigate contemporary midterm outcomes of isolated thoracic aortic replacement in patients with CTD versus degenerative pathology in a large institutional cohort.
All patients undergoing isolated open thoracic aortic replacement at a single academic center from 2005 to 2020 were included. Patients were classified as having CTD or not having CTD based on documented genetic mutations associated with congenital aortopathy. In-hospital and midterm outcomes, including mortality, paraplegia, development of new arterial pathology on surveillance imaging, and the need for future operations, were compared between groups using descriptive statistics and Kaplan-Meier survival analysis.
Overall, 62 patients were included with a median follow-up of 58 months (range, 19-81 months) (59 months for those with CTD vs 51.5 months for those without CTD). CTD was present in 18 patients (29%), with 16 having Marfan syndrome (77.8%). Patients with CTD were younger than patients without CTD (45.8 years vs 60.9 years) and had lower rates of smoking (5.6% vs 56.8%) and hypertension (97.7% vs 72.2%; all P < .01). Patients with CTD were more likely to have a dissection component at the time of repair compared with patients without CTD (100% vs 59.1%) and underwent repair at smaller aortic diameters (5.9 cm vs 6.6 cm; both P < .05). There were no differences in in-hospital outcomes between the two groups, including mortality (4.5% vs 5.6%) and paraplegia (2.3% vs 0%; both P > .05). At 5 years, patients with CTD were more likely to have developed aneurysmal changes distal to their thoracic repair (88.9% vs 47.7%) and extra-aortic arterial aneurysms (41.2% vs 2.3%; both P < .05). However, on survival analysis, there were no differences in freedom from additional vascular procedures (hazard ratio,1.76; P = .333) or, specifically, additional aortic procedures (hazard ratio, 1.81; P = .380) between the two groups. There was only one anastomotic complication identified on longitudinal follow-up, which occurred in a patient without CTD 8 years after the index operation.
Although carrying significant operative risks and the potential for morbidity, open thoracic aortic replacement represents a well-tolerated, durable treatment option for patients with congenitally mediated thoracic aortic disease. Because both patients with and without CTD who required thoracic aortic replacement often need future aortic intervention, vigilant surveillance is warranted. Equivalent intervention rates between the two groups suggest remodeling of the CTD aorta is almost universally characterized by initial postrepair dilation, but the majority of these changes successfully stabilize and do not progress to higher rates of intervention.

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: This document is a Report from The Society of Thoracic Surgeons Endovascular Surgery Task Force; Nicholas T. Kouchoukos, MD (Task Force Chair); Joseph E. Bavaria, MD; Joseph S. Coselli, MD; Ralph de la Torre, MD; Thomas G. Gleason, MD; John S. Ikonomidis, MD; Riyad C. Karmy-Jones, MD; R. Scott Mitchell, MD; Richard J. Shemin, MD; David Spielvogel, MD; Lars G. Svensson, MD; and Grayson H. Wheatley. This report was developed with input from cardiologist and vascular surgeon authors and has been endorsed by the American Association for Thoracic Surgery. Copyright 2008 The Society of Thoracic Surgeons.

: The Society of Thoracic Surgeons Expert Consensus Documents may be printed or downloaded for individual and personal use only. Expert Consensus Documents may not be reproduced in any print or electronic publication or offered for sale or distribution in any format without the express written permission of The Society of Thoracic Surgeons.

: The STS Expert Consensus Documents are intended to assist physicians and other health care providers in clinical decision-making by describing a range of generally acceptable approaches for the diagnosis, management, or prevention of specific diseases or conditions. This document should not be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the same results. Moreover, the expert consensus is subject to change over time, without notice. The ultimate judgment regarding the care of a particular patient must be made by the physician in light of the individual circumstances presented by the patient.

^⁎: Expert Consensus Document on the Treatment of Descending Thoracic Aortic Disease Using Endovascular Stent-Grafts has been supported by Unrestricted Educational Grants from Cook, Inc and Medtronic, Inc.

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Report from The Society of Thoracic Surgeons Endovascular Surgery Task ForceExpert Consensus Document on the Treatment of Descending Thoracic Aortic Disease Using Endovascular Stent-Grafts⁎

Section snippets

Natural History of Descending Thoracic Aortic Aneurysms

Growth Rate of Aortic Aneurysms

Contemporary Results of Open Surgical Graft Replacement of the Thoracic Aorta

Indications for Operative Intervention

Penetrating Aortic Ulcers

The Gore TAG Thoracic Endograft

Abdominal Aortic Aneurysm Treatment

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Am J Cardiol

Am J Cardiol

Am Heart J

Am Heart J

J Vasc Surg

J Thorac Cardiovasc Surg

J Vasc Interv Radiol

Eur J Vasc Endovasc Surg

Am J Cardiol

Cardiol Clin

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Am Heart J

J Thorac Cardiovasc Surg

Am J Cardiol

J Thorac Cardiovasc Surg

Am J Cardiol

Radiol Clin North Am

Am J Cardiol

Am J Med

J Vasc Surg

Ann Thorac Surg

Am J Cardiol

J Vasc Surg

Ann Vasc Surg

J Vasc Surg

J Am Coll Cardiol

J Am Soc Echocardiogr

J Vasc Surg

Ann Thorac Surg

Chest

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Vasc Surg

J Thorac Cardiovasc Surg

J Vasc Surg

Eur J Vasc Endovasc Surg

Eur J Vasc Endovasc Surg

Chest

Ann Thorac Surg

Report from The Society of Thoracic Surgeons Endovascular Surgery Task Force
Expert Consensus Document on the Treatment of Descending Thoracic Aortic Disease Using Endovascular Stent-Grafts^⁎