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undergoing elective TEVAR, the statin prescription percentage should be considered a quality metric.

4 Descending Thoracic Aortic Aneurysms (DTAA) and Thoracoabdominal Aortic…

4.4.3 Anaesthesia andAnalgesia

4.4.3.1 Epidural Analgesia, Paravertebral Block andIntercostal

Nerve Cryoanalgesia

Epidural analgesia (EA) is not widely used in patients undergoing open TAAA repair, probably owing to the risks of epidural haematoma in patients who need systemic heparinisation and who are at high risk of developing perioperative coagulopathy secondary to massive bleeding. In addition, thoracic epidural anaesthesia may alter early post-operative neurological evaluation, in a setting in which neurological complications, mainly paraplegia, warrant prompt diagnosis and immediate treatment. Monaco et al. [33] reported on 459 patients undergoing open TAAA repair, of whom 409 (89%) received thoracic epidural anaesthesia. Exclusion criteria for EA included dual antiplatelet medication and clopidogrel discontinuation <7days. After propensity score matching, 43 patients in the conventional analgesia group were compared with 43in the thoracic epidural analgesia group. Thoracic epidural analgesia showed a signicant reduction in post-operative pain (p<.001) and no differences in the incidence of acute kidney injury, atrial brillation, acute myocardial infarction, and paraplegia. In the thoracic epidural analgesia group, there were no epidural haematomas. The use of thoracic epidural analgesia, if not contraindicated, might be considered for open TAAA repair, as it could improve peri-operative management and promote recovery.

Paravertebral block is reported to be just as effective as epidural analgesia in

relieving post-thoracotomy pain, with a signicantly lower neurological risk. Minami etal. [34] reported on their experience with 56 consecutive patients who underwent open TAAA repair. 17 patients received the paravertebral block, 39 did not. Paravertebral block signicantly reduced numeric rating scale (NRS) scores of postoperative pain at rest and while coughing, and signicantly reduced the reintubation rate, the rate of noninvasive positive-pressure ventilation (NPPV), and postoperative pneumonia without complications. Paravertebral block is an effective analgesic method that may reduce postoperative respiratory exacerbations in patients undergoing TAAA repair.

Tanaka etal. [35] reviewed the efcacy of intraoperative intercostal nerve cryo-

analgesia for pain control in patients undergoing open descending TAA and TAAA repairs. 241 patients underwent TAA or TAAA repair. Of those, 38 patients were treated with intraoperative cryoanalgesia to the intercostal nerves at the level of fourth to tenth under electromyography guidance and were compared with patients who did not receive cryoanalgesia. For cryoanalgesia, the CryoICE CRYO2 cryoablation probe (AtriCure) was used. One hundred twenty-six patients met the inclusion criteria: 28in the cryoanalgesia group and 98in the control group. Both groups

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received multilevel paravertebral block and local inltration with liposomal bupivacaine. Postoperative major complications, length of stay, and discharge to home were not signicantly different in either group. However, median ventilation hours were signicantly shorter in the cryoanalgesia group (5 vs 12h, P<.001). Opioid use was signicantly less in the cryoanalgesia group after postoperative day 4. Indexed morphine milligram equivalences, adjusted with body surface area, and numerical pain scale scores were signicantly lower in the cryoanalgesia group throughout the postoperative course. Intercostal nerve cryoanalgesia provided improved pain control after TAA and TAAA repairs. One of the limitations of local anesthetic inltration is that the effect may only last for hours to a few days. On the contrary cryoanalgesia nerve block may be effective for more than 1month.

Another series of patients with cryoablation was reported by Clemence etal.

[36]. Among 117 patients undergoing open TAA or TAAA repair, 25 patients received cryoablation of their intercostal nerves. There were no signicant differences between the non-cryoablation and cryoablation groups in postoperative stroke, paraplegia (5%), pneumonia, and in-hospital mortality (0.9%). However, the average usage of narcotics was signicantly reduced in the cryoablation group. Cryoablation of intercostal nerves was a safe and effective measure for postoperative pain control in TAA or TAAA repair.

4.4.4 Neurophysiological Monitoring

4.4.4.1 Clinical Practice Guidelines oftheEuropean Society forVascular

Surgery (ESVS) [1]

Spinal cord function monitoring:

• During open thoracic or thoracoabdominal aortic repair, perioperative monitoring of motor and/or somatosensory evoked potentials may be considered to predict spinal cord ischaemia. (Class IIb recommendation/Evidence level C).

4.4.4.2 Studies

Estrera etal. [37] reported their experience with neuromonitoring-guided open thoracoabdominal aortic aneurysm repair. 105 thoracic aorta repairs were performed; 89% of patients (93/105) underwent repair using cerebrospinal uid drainage and distal aortic perfusion. In addition, somatosensory and motor evoked potentials were monitored during repair, and active intraoperative maneuvers were undertaken in response to changes in the signals. Intraoperative maneuvers included intercostal artery reimplantation. In-hospital mortality was 5.7% (6/105). Immediate spinal cord injury occurred in 1 patient (1%), and 3 patients (3%) had delayed neurologic decit. Intercostal arteries were reattached in 85% of possible cases (51/60).

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Somatosensory evoked potentials achieved adequate readings in 99% of cases (102/103). Loss of somatosensory evoked potential was encountered in 26% of cases (27/102), and return of somatosensory evoked potentials occurred in all cases after intraoperative maneuvers. Motor evoked potentials achieved adequate readings in 96% of cases (99/103). Loss of motor evoked potential was encountered in 50% of cases (50/99), and return of motor evoked potentials occurred in all but 1 case (95%). This patient awoke with an immediate spinal neurologic decit. Neuromonitoring using somatosensory evoked potentials and motor evoked potentials seems useful during TAAA repair. Note: Motor evoked potentials (MEPs) disappear in the presence of neuromuscular blocking agents, and volatile anaesthetics also cause dose-dependent depression of the MEP at doses within the range used in clinical practice. Total i.v. anaesthesia is preferred if MEPs are to be used [38].

endovascular repair 50.5%) with TAA or TAAA repair. MEP monitoring was performed in 631 patients and not performed in the remaining 583 patients. Postoperative motor decits were observed in 75 (6.2%) patients at discharge, 50 (8.3%) after open and 25 (4.1%) after endovascular repair. Multivariable logistic regression analysis revealed that postoperative motor decits at discharge did not have a signicant association with MEP monitoring (adjusted odds ratio [OR], 1.13; 95% condence interval [CI], 0.69–1.88; P= .624). The analysis revealed that a history of neural decits due to cerebral infarction, spinal disease, spinal drainage, and other neurological diseases were associated with an increased incidence of postoperative motor decits. Alternatively, endovascular procedures were found to be protective.

4 Descending Thoracic Aortic Aneurysms (DTAA) and Thoracoabdominal Aortic…

Yoshitani et al. [39] reviewed data from 1214 patients (open surgery 49.5%;

4.4.5 Prevention ofSpinal Cord Ischaemia

4.4.5.1 Clinical Practice Guidelines oftheEuropean Society forVascular

Surgery (ESVS) [1]

Recommendations for open TAA repair:

• Cerebrospinal uid drainage has a role in the prevention of paraplegia and paraparesis and should be considered during extensive open repair of the descending thoracic aorta. (Class IIa; Level of evidence B).

• To prevent spinal cord ischaemia, left heart bypass, allowing distal perfusion, during open type I and II thoraco-abdominal aortic aneurysm repair should be considered. (Class IIa; Level of Evidence C).

• During extensive open descending thoracic aorta repair, moderate hypothermia around 32°C may be considered to prevent spinal cord ischaemia. (Class IIb; Level of Evidence C).

• Systemic cooling to less than 32°C in combination with CSF drainage is not recommended during open descending thoracic aortic repair as it can increase the risk of subdural bleeding. (Class III; Level of evidence B).

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Prevention of spinal cord ischaemia in thoracic endovascular repair (TEVAR):

• Patients with planned extensive thoracic aorta coverage (> 200mm) or previous abdominal aortic aneurysm (AAA) repair have a high risk for spinal cord ischaemia and prophylactic CSF drainage should be considered in endovascular thoracic aorta repair. (Class IIa; Level of Evidence C).

4.4.5.2 Recommendations oftheU.S.Aortic Research Consortium [40]

This group dened patients at high risk for spinal cord ischaemia during endovascular repair of complex aortic aneurysms as follows:

• Crawford extent I, II, III thoracoabdominal aortic aneurysms (TAAA) (intended aortic coverage).

• Previous open or endovascular infrarenal aortic surgery.

• “Shaggy” atheromatous aorta.

• Abnormal pelvic perfusion: unilateral hypogastric artery occlusion or bilateral hypogastric artery stenosis.

• Abnormal bilateral vertebral or abnormal left vertebral artery perfusion.

Recommendations for spinal cord protection practices are listed in Table4.4. In the postoperative setting, the group recommended hourly neurovascular examinations to evaluate the patient’s ability to lift each leg off the bed while a CSF drain is in place. If the patient shows any signs of weakness or deciency in proprioception, SCI should be suspected, and rescue maneuvers should be initiated. These measures are listed in Table4.5.

4.4.5.3 Studies

An analysis of the VQI database from 2014 to 2019 is available on CSF drain use in complex endovascular aortic repair (TEVAR/cEVAR) [41]. There were a total of 3406 TEVAR/cEVAR procedures, with an overall spinal cord ischemia (SCI) rate of

2.3%. Among 72 patients with SCI, 48 had received prophylactic CSF drain place-

ment and 24 had received therapeutic drain placement. The SCI outcome was signicantly worse for the therapeutic group because 79% had documented permanent paraplegia at discharge compared with 54% of the prophylactic group (P=.04). SCI patients receiving a postoperative therapeutic CSF drain had worse survival than those with a preoperative prophylactic CSF drain (50%±10% vs 71%±9%; logrank P = .1; Wilcoxon P= .05). These ndings speak in favour of preoperative prophylactic CSF drain placement and highlight the need for a randomized clinical trial to examine prophylactic vs therapeutic CSF drain placement in association with TEVAR/cEVAR.

Alqaim etal. [42] reported on their experience with lumbar CSF drainage in 100

patients who underwent fenestrated or branched endovascular aneurysm repair (F/

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Table 4.4 Recommendations for spinal cord protection practices used by the U.S.Aortic Research Consortium during endovascular repair of complex TAAA [40]

Protective method Recommended practice

Blood pressure elevation

Higher haemoglobin goal

CSF drain placement Placement of a preoperative prophylactic CSF drain should be

Repair in staged fashion

Revascularisation of spinal cord collaterals

4 Descending Thoracic Aortic Aneurysms (DTAA) and Thoracoabdominal Aortic…

ACE inhibitors should be withheld for 48h preoperatively and resumed postoperatively when the patient is ready for discharge

β-Blockade should be continued pre- and postoperatively Mean arterial blood pressure goal should be not <90mmHg

intraoperatively and continued for not >72h postoperatively (or until removal of CSF drain is present)

Blood pressure medication should be resumed within the rst 1–2weeks postoperatively. However, if systolic blood pressure is >200mmHg, resumption of antihypertensive medication within the rst week should be considered

Perioperative haemoglobin goal should be ≥10mg/dl, with maintenance of haemoglobin goal of ≥10mg/dl for not >72h postoperatively (or until removal of CSF drain is presnt)

considered for Crawford extent I, II, and III TAAA intended aortic coverage and for otherwise “high-risk” patients

If a CSF drain was not placed preoperatively, a protocol should be in place for expeditious postoperative therapeutic placement

A staged approach should be used for Crawford extent I, II, and III TAAA

Revascularisation of the left subclavian artery and any occluded hypogastric arteries should be performed when possible

Table 4.5 Rescue maneuvers for suspected spinal cord ischaemia. Recommendations of the U.S.Aortic Research Consortium [40]

Rescue maneuver Recommended practice

CSF drain placement Placement of a therapeutic CSF drain if no prophylactic drain was

placed If a prophylactic was placed, the target CSF drain pop-off pressure

should be decreased approximately 5mmHg from baseline (but not <5mmHg)

Increased CSF drainage should be allowed, but not >30ml/h, with

close monitoring for signs of intracerebral haemorrhage High haemoglobin goal Conrmation of a haemoglobin goal of ≥10mg/dl Elevate mean arterial

blood pressure goal Immediate CT or MR of

the spine

Maintenance of an elevated mean arterial blood pressure goal of not

<90mmHg

Evaluation for external compression on the spinal cord from a

haematoma that might require surgical evacuation

BEVAR). Successful placement occurred in 98 (98%) of the cases. All lumbar drains were placed before induction of general anesthesia, using uoroscopy guidance in 28 cases (28%). The majority (82%) were left in place ≤48h. Nonfunctionality was the most common complication, occurring in 16 (16%) patients. Catheter dislodgment or fracture, CSF leak, and postdural puncture headache were observed in

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4 (4%), 7 (7%), and 4 (4%) patients, respectively. The most common bleeding complication was the presence of asymptomatic blood in the CSF (11%), whereas subarachnoid hemorrhage combined with intraventricular hemorrhage occurred in three patients (3%); none of these patients required surgical drainage or intervention. No infectious complications were observed. These experiences demonstrate that lumbar drain placement can be performed successfully but is associated with a signicant rate of nonfunctionality and a diverse range of complications. Therefore, placement of a prophylactic lumbar drain to avert SCI risk should always be weighed against the risk of drain complications.

Potential serious complications associated with perioperative lumbar drain (LD) placement for endovascular aortic repair were also highlighted by Plotkin etal. [43]. A total of 309 LDs had been placed in 268 consecutive patients for 222 thoracic endovascular aortic repairs, 85 complex endovascular aortic repairs, and 2 EVARs. Most drains were placed prophylactically (96%), with a technical success rate of 98%. The overall complication rate was 8.1% (4.2% major and 3.9% minor). Major complications included spinal haematoma with paraplegia in 1 patient, intracranial haemorrhage in 2 patients, meningitis in 2 patients, arachnoiditis in 3 and CSF leak requiring a blood patch in 3 patients. Patients who had undergone previous LD placement had experienced signicantly more major LD-related complications (12.2% vs. 3%). The rate of total LD-associated complications did not differ between prophylactic and emergent therapeutic placements (8.1% vs 7.7%; P = 1.00). The complications associated with LD placement can be severe even when performed by a dedicated team. Although these risks are justied for therapeutic LD placement, the benet of prophylactic LD placement to prevent paraplegia should be weighed against these serious complications.

The need to carefully weigh the benets and harms of CSF drainage (CSFD) is also underlined by the ndings of Kärkkäinen etal. [44]. These authors assessed CSF drainage-related complications in 187 patients undergoing rst-stage or completion fenestrated branched endovascular repair for pararenal or thoracoabdominal aortic aneurysms. Nineteen patients (10%) had 22 CSF drainage-related complications after 21 aortic procedures (9%). Complications were graded as severe to moderate in 17 patients (9%). There were 12 patients (6%) with intracranial hypotension, including three (2%) who had intracranial hemorrhage and nine (5%) with post dural puncture headache requiring blood patches in six. Another six patients (3%) developed spinal hematomas resulting in paraplegia in two (1%) and transient paraparesis in two (1%). Technical difculties were experienced in 57 drain insertions (24%). Of 13 study patients who developed spinal cord injuries during aortic procedures, 4 (31%) were attributed to CSFD.Because of the high rate of spinal hematomas, the authors no longer recommend CSFD during rst-stage TEVARs or for patients with pararenal or extent IV TAAAs who require shorter segments of supraceliac coverage. In addition, CSFD is individualized for patients with extent III TAAAs and used routinely for extent I and II TAAAs. Given the potential for serious complications, the risks of prophylactic CSFD should be carefully weighed against its potential benets.

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patients with TAAAs treated with F/B-EVAR.Prophylactic CSFD was used in 78 patients (73.6%), and 28 patients (26.4%) underwent F/B-EVAR without CSFD.Four patients (3.8%) with prophylactic drainage developed spinal cord ischaemia (SCI), including two patients with permanent paraplegia and two patients with paraparesis. Multivariate analysis revealed that greater extent of thoracic aortic coverage and intraoperative blood loss were the signicant risk factors for SCI.Six patients (7.6%) experienced major CSFD-related complications, including subarachnoid hemorrhage in 2.6% (2), spinal hematoma in 2.6% (2), cerebellar hemorrhage in 1.3% (1), and spinal drain fracture requiring surgical laminectomy in 1.3% (1). Technical difculties during CSFD catheter placement were noted in seven patients (9.0%). The incidence of SCI after F/B-EVAR with selective CSFD was low, and risk factors for SCI were greater with extent of thoracic aortic coverage and intraoperative blood loss. However, the incidence of major CSFD-related complications exceeded the incidence of SCI, and CSFD signicantly increased both intensive care unit and total hospital length of stay. Therefore, routine prophylactic CSFD may not be justied, and a prospective randomized trial of CSFD in patients undergoing F/B-EVAR seems appropriate.

4 Descending Thoracic Aortic Aneurysms (DTAA) and Thoracoabdominal Aortic…

The report by Kitpanit etal. [45] is also critical. They analysed 106 consecutive

4.4.6 Transfusion Strategy

Monaco etal. [46] performed a propensity score matched study to assess whether the introduction of a rotational thromboelastometry (ROTEM) based transfusion strategy reduces allogenic blood transfusion and affects morbidity in patients undergoing open TAAA repair. 547 consecutive patients were included. After propensity score matching, 77 patients in the ROTEM algorithm group were successfully matched with 77 patients in the standard algorithm group. During the study period, all patients received intraoperative infusion of tranexamic acid (1g over 20min followed by 250mg/h) to prevent hyperbrinolysis. A cellsaver machine was used to process and re-infuse salvaged blood. If needed, left heart bypass was used. The target activated clotting time (ACT) during bypass was >190s. Heparin was administrated at a maximum starting dose of 70IU/kg and reversed at the end of surgery with protamine in a 1:1 ratio. ACT was serially assessed during surgery and additional heparin was administered as necessary. Packed RBCs were transfused if the haematocrit was <30%. ROTEM tests were performed in all patients after heparin reversal with protamine. As the aim of ROTEM is to treat peri-operative coagulopathy associated with microvascular bleeding, the test was only performed after all surgical sources of bleeding were under control. In the event of a maximum clotting rmness in the EXTEM (extrinsic) < 45 mm and in the FIBTEM (brinogen)<8mm, 2g of brinogen were administered. Conversely with a clotting rmness in the FIBTEM >10 mm, platelets were transfused. Patients managed with ROTEM received fewer red blood cells units (and a lower volume of fresh frozen plasma. In addition, fewer patients received fresh frozen plasma (35% vs. 97%;

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p<.001). Patients in the ROTEM group showed a signicant decrease in the occurrence of pulmonary complications (44% vs. 83%; p=.01). In conclusion, a ROTEM guided transfusion strategy signicantly limited the quantity of transfused blood products during open TAAA repair, improving clinical outcomes while reducing costs, allowing for better resource distribution in a setting where blood loss is relevant.

4.4.7 Minimally Invasive Segmental Artery Coil Embolisation

toPrevent Spinal Cord Ischaemia

Sequential coil embolisation of intercostal arteries has been suggested as a method to protect the spinal cord after TEVAR through stimulation of collateral ow of the spinal cord [47]. The value of the procedure cannot yet be assessed [48], but a feasibility study is now available in 57 patients who underwent ischaemic preconditioning using minimally invasive segmental coil embolisation prior to endovascular TAAA repair [49]. The time interval between the last session of coiling and the complete exclusion of the aneurysm was a median of 65days (mean 83±62days) with a wide range (7–248). Endovascular exclusion of the thoracoabdominal aneurysm was performed in 55 patients. 1 patient died postoperatively, and none of the 54 patients alive after the complete exclusion of their aneurysm developed spinal cord ischaemia. Minimally invasive segmental artery coil embolisation (MISACE) to precondition the paraspinous collateral network is clinically feasible, but the ultimate proof of MISACE’s success requires a randomised trial. The trial protocol for a randomised controlled multicentre has been published, where 500 patients will be randomised in a 1:1 ratio to standard aneurysm repair or to MISACE in 1–3 sessions followed by repair. The study intends to include endovascular or open repair of TAAA, Crawford type II or III [50].

4.4.8 Thromboprophylaxis

4.4.8.1 Guidelines

There are no specic guideline recommendations for thromboprophylaxis in patients with endovascular or open TAA repair. Only the guidelines of the American College of Chest Physicians [51] recommend for patients with TAAA repair VTE (Venous Thromboembolism) prophylaxis with low molecular weight heparin (LMWH) by analogy to major abdominal-pelvic surgery patients. The risk of thrombosis must be balanced against the risk of bleeding, especially with concomitant anticoagulant therapy and platelet aggregation inhibition.

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4.4.8.2 Studies

Ramanan etal. [52] used the NSQIP database to dene the incidence of overall and postdischarge VTE after major vascular operations and assess risk factors associated with VTE development. 45,548 vascular procedures were identied including 361 patients with open thoracoabdominal aortic aneurysm (TAAA) repair and 732 thoracic endovascular aortic repairs (TEVAR). Open TAAA repair and TEVAR had the highest rates of VTE among all vascular procedures identied, at 4.2% and

2.2%, respectively. The authors attributed this to the fact that spinal drains are placed for protection from paraplegia in most patients undergoing TAAA repairs and in many undergoing TEVARs, and consequently, they do not receive VTE prophylaxis for the rst 48 to 72h. As a signicant proportion of VTE events were observed after discharge, the authors recommended continuing VTE prophylaxis even beyond patient discharge. Aziz etal. [53] also emphasised the high incidence of VTE after vascular surgery, which was higher among cardiac surgery (2%) and vascular surgery (0.99%) patients as compared with that of general surgery patients (0.66%). They emphasised that apparently intraoperative anticoagulation does not prevent the occurrence of deep venous thrombosis (DVT) in the postoperative period. They recommended that these patients should receive DVT prophylaxis in the perioperative period, like other surgical patients, but did not provide data specically on TAA.

4 Descending Thoracic Aortic Aneurysms (DTAA) and Thoracoabdominal Aortic…

4.4.9 Endoleak

4.4.9.1 The European Society forVascular Surgery (ESVS) Clinical

Practice Guidelines Recommend [1]

• Any early or late type I or III endoleak after endovascular repair of the descend-

ing thoracic aorta should undergo prompt intervention (recommendation class 1,

level of evidence C).

• Type II and IV endoleaks may be followed by serial CTA/MRI at 3 and 6months.

If the aneurysm sac grows >10mm, endovascular or open repair is required. If

the aneurysm sac growth is <10mm, CTA/MRI is indicated at 3 and 6months.

4.4.9.2 Reviews

Ameli-Renani etal. [54] reviewed the treatment options for secondary endoleaks after EVAR and TEVAR, dened as those detected more than 30days after the procedure and after previous negative imaging. They summarized classication of endoleaks and their management as shown in Table4.6.

Belvroy etal. [55] performed a systematic review of the literature on endoleak type 1b, in patients with aortic aneurysm after TEVAR based on 16 studies. The

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Table 4.6 Summary of classication of endoleaks and their management [54]

Endoleak Cause of sac perfusion Management

1 Flow from the proximal or distal

graft attachment site

1a Proximal graft attachment site Angioplasty, Palmaz or cuff extension,

1b Distal graft attachment site Angioplasty and extension of distal limb 1c Endoleak at the site of an iliac

occluder plug

2 Retrograde ow through patent

aortic side branch vessels 3 Mechanical graft failure Prompt 3a Modular disconnection

Leak at a fenestration, branch or

visceral stent 3b Fabric tear Relining the endograft by deploying a new

4 Graft porosity Conservative

5 Sac size increase with no visible

Endoleak (Endotension)

Prompt

chimney extension and embolisation

Insertion of an additional iliac occluder plug or embolisation

Conservative if sac size stable. Embolisation if sac size increase

Placement of additional endograft components

endograft within the preexisting graft

Transient phenomenon May consider catheter angiography with cone

beam CT

reported incidence of early endoleaks (< 30days after intervention) was 1.3–8.1% and that of late endoleaks (> 30days after intervention) 3.1% to 5%. Treatment was required in most cases and was usually performed with distal extension of the stent graft.

A systematic review and meta-analysis summarises the evidence for endoanchor use in EVAR and TEVAR to treat type Ia endoleak (TIaE) and graft migration [56]. In patients where endoanchors were used during the primary EVAR procedure, the rate of TIaE was 3.5% at a mean follow up of 15.4months. A total of 107 EVAR patients underwent secondary xation with a technical success of 91.8%. 74 patients were available at a mean follow up of 10.7months. Of the 74 secondary patients available, 22.6% had a post-operative TIaE.Of those treated exclusively for TIaE,

39.3% continued to have persistent endoleak despite endoanchors. Alternative strategies such as proximal endograft extension may have better outcomes for treating established TIaE.Evidence for endostapling in TEVAR was sparse. A total of 66 TEVAR patients underwent endoanchor xation (29 primary, 31 secondary, six indeterminate). Technical success in endoanchor deployment was 90.3%. The overall rate of TIaE was 8.7%. The weighted all cause 30-day mortality was 11.9%. Compared to EVAR, endostapling in TEVAR is associated with lower technical success, higher perioperative mortality, and potential serious adverse events. The current evidence is hindered by short term follow up and lack of case controlled trials, among other drawbacks, to recommend endoanchor use in routine clinical practice.

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