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References
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65
a nitinol stent was detected on the 2-year follow-up CT, with no consequences. No
recurrence of ischemia was observed. Aortic diameter increased signicantly over
time (P=.0038) at a mean rate of 1.46mm/year. Two patients had a signicantly
increased aortic thoracic diameter (9%) and needed surgical treatment.
3.6 Conclusions forClinical Practice
1. Optimal medical therapy (OMT) is the recommended treatment for patients with
uncomplicated type B aortic dissection (TBAD). To avoid aortic complications
in uncomplicated acute type B aortic dissection, early endovascular repair
(TEVAR) may be considered selectively.
2. TEVAR is indicated for complicated hyperacute, acute or subacute TBAD with
rupture and/or malperfusion and favourable anatomy. Open surgical management should be considered in patients with complicated hyperacute, acute or
subacute TBAD with anatomy unsuitable for TEVAR.
3. In chronic type B aortic dissection, there is an early survival advantage and a
lower rate of major complications of standard TEVAR over open repair. The
reintervention rate for TEVAR due to chronic dissection is relatively high, but
the medium-term survival is similar for TEVAR and open repair.
4. Referral of the patient to a centre with a high surgical case volume is associated
with signicantly lower hospital mortality, especially in the case of open repair
of type B aortic dissection and is urgently recommended.
References
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of descending thoracic aorta diseases: clinical practice guidelines of the European Society for
Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2017;53:4–52.
2. Isselbacher EM, Preventza O, Hamilton Black J, et al. 2022 ACC/AHA guideline for the
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3. Czerny M, Schmidli J, Adler S, van den Berg JC, Bertoglio L, Carrel T, Chiesa R, Clough RE,
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T, Rylski B, Schoenhoff F, Shrestha M, von Tengg-Kobligk H, Tsagakis K, Wyss TR, EACTS/
ESVS Scientic Document Group. Current options and recommendations for the treatment
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European Association for Cardio-Thoracic surgery (EACTS) and the European Society for
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4. Booher AM, Isselbacher EM, Nienaber CA, Trimarchi S, Evangelista A, Montgomery DG,
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5. MacGillivray TE, Gleason TG, Patel HJ, etal. The Society of Thoracic Surgeons/American
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sur.2021.11.002. Epub ahead of print.
6. Hossack M, Patel S, Gambardella I, Neequaye S, Antoniou GA, Torella F.Endovascular vs.
medical management for uncomplicated acute and sub-acute type B aortic dissection: a metaanalysis. Eur J Vasc Endovasc Surg. 2020;59:794–807.
7. Wang J, Jin T, Chen B, Pan Y, Shao C.Systematic review and meta-analysis of current evidences in endograft therapy vs medical treatment for uncomplicated type B aortic dissection.
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8. Howard C, Sheridan J, Picca L, etal. TEVAR for complicated and uncomplicated type B aortic
dissection-systematic review and meta-analysis. J Card Surg. 2021;36:3820–30.
9. Li HL, Wu S, Chan YC, Cheng SW, Guo W, Xiong J.Early and mid-term mortality and morbidity of contemporary international endovascular treatment for type B aortic dissection—a
systematic review and meta-analysis. Int J Cardiol. 2020;301:56–61.
10. Harky A, Chan JSK, Wong CHM, Francis N, Grafton-Clarke C, Bashir M.Systematic review
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Vasc Surg. 2019;69:1599–609.
11. Bou M, Patterson BO, Loundou AD, Boyer L, Grima MJ, Loftus IM, Holt PJ.Endovascular
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2019;107:1559–70.
12. Jordan F, FitzGibbon B, Kavanagh EP, McHugh P, Veerasingam D, Sultan S, Hynes
N.Endovascular versus open surgical repair for complicated chronic type B aortic dissection.
Cochrane Database Syst Rev. 2021;12:CD012992.
13. Lou X, Chen EP, Duwayri YM, Veeraswamy RK, Jordan WD Jr, Zehner CA, Leshnower
BG.The impact of thoracic endovascular aortic repair on long-term survival in type B aortic
dissection. Ann Thorac Surg. 2018;105:31–8.
14. Schwartz SI, Durham C, Clouse WD, Patel VI, Lancaster RT, Cambria RP, Conrad
MF.Predictors of late aortic intervention in patients with medically treated type B aortic dissection. J Vasc Surg. 2018;67:78–84.
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P, DeMartino RR.Improving mortality trends for hospitalization of aortic dissection in the
National inpatient sample. J Vasc Surg. 2016;64:606–15.
16. Hsieh RW, Hsu TC, Lee M, Hsu WT, Chen ST, Huang AH, Hsieh AL, Lee CC.Comparison
of type B dissection by open, endovascular, and medical treatments. J Vasc Surg.
2019;70:1792–800.
17. Xiang D, Kan X, Liang H, Xiong B, Liang B, Wang L, Zheng C.Comparison of mid-term outcomes of endovascular repair and medical management in patients with acute uncomplicated
type B aortic dissection. J Thorac Cardiovasc Surg. 2021;162:26–36.
18. Wang GJ, Cambria RP, Lombardi JV, Azizzadeh A, White RA, Abel DB, Cronenwett JL, Beck
AW.Thirty-day outcomes from the society for vascular surgery vascular quality initiative thoracic endovascular aortic repair for type B dissection project. J Vasc Surg. 2019;69:680–91.
19. Torrent DJ, McFarland GE, Wang G, Malas M, Pearce BJ, Aucoin V, Neal D, Spangler EL,
Novak Z, Scali ST, Beck AW.Timing of thoracic endovascular aortic repair for uncomplicated acute type B aortic dissection and the association with complications. J Vasc Surg.
2021;73:826–35.
20. Xie E, Yang F, Liu Y, Xue L, Fan R, Xie N, Chen L, Liu J, Luo J.Timing and outcome of
endovascular repair for uncomplicated type B aortic dissection. Eur J Vasc Endovasc Surg.
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21. Wang GJ, Jackson BM, Damrauer SM, Kalapatapu V, Glaser J, Golden MA, Schneider
D. Unique characteristics of the type B aortic dissection patients with malperfusion in the
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3 Distal Aortic Dissection Type Stanford B
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22. Carroll BJ, Schermerhorn M, Kennedy KF, Swerdlow N, Soriano KM, Yeh RW, Secemsky
EA.Readmissions after acute type B aortic dissection. J Vasc Surg. 2020;72:73–83.
23. Ding H, Liu Y, Xie N, Fan R, Luo S, Huang W, Li J, Zhu Y, Hu B, Xue L, Luo J.Outcomes of
chimney technique for preservation of the left subclavian artery in type B aortic dissection. Eur
J Vasc Endovasc Surg. 2019;57:374–81.
24. Chia MC, Khorfan R, Eskandari MK.Adjunctive branch interventions during thoracic endovascular aortic repair for acute complicated type B dissection are not associated with inferior
outcomes. J Vasc Surg. 2021;74:895–901.
25. Chang H, Rockman CB, Cayne NS, Veith FJ, Jacobowitz GR, Siracuse JJ, Patel VI, Garg
K.Anticoagulation and antiplatelet medications do not affect aortic remodeling after thoracic
endovascular aortic repair for type B aortic dissection. J Vasc Surg. 2021;74:1833–42.
26. Canaud L, Faure EM, Ozdemir BA, Alric P, Thompson M.Systematic review of outcomes of
combined proximal stent-grafting with distal bare stenting for management of aortic dissection. Ann Cardiothorac Surg. 2014;3:223–33.
27. Bertoglio L, Rinaldi E, Melissano G, Chiesa R.The PETTICOAT concept for endovascular
treatment of type B aortic dissection. J Cardiovasc Surg. 2019;60:91–9.
28. Rong D, Ge Y, Liu J, Liu X, Guo W.Combined proximal descending aortic endografting plus
distal bare metal stenting (PETTICOAT technique) versus conventional proximal descending
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30. Chen IM, Huang CY, Weng SH, Lin PY, Chen PL, Chen WY, Shih CC.Implantation sequence
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Chapter 4
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Descending Thoracic Aortic Aneurysms
(DTAA) andThoracoabdominal Aortic
Aneurysms (TAAA)
4.1 Guidelines
4.1.1 Clinical Practice Guidelines oftheEuropean Society
forVascular Surgery (ESVS)
The clinical practice guidelines of the European Society for Vascular Surgery
(ESVS) recommend for treatment of descending aortic aneurysms [1]:
• Open repair (OR) may be considered for t patients, with a descending thoracic
aorta between 56 to 59mm in diameter, who are unsuitable for endovascular
treatment. (Class IIb; Level of evidence C).
• OR should be considered for t patients, with a descending thoracic aorta exceed-
ing 60mm in diameter, who are unsuitable for endovascular treatment. (Class
IIa; Level of evidence C).
• To reduce the rate of postoperative paraplegia, left heart bypass is not recom-
mended for patients undergoing open repair for descending thoracic aneurysm.
(Class III; Level of evidence C).
• In t and unt patients with favourable anatomy, endovascular repair may be
considered for descending thoracic aorta aneurysms between 56 and 59 mm
diameter. (Class IIb; Level of evidence B).
• In t and unt patients with favourable anatomy, endovascular repair should be
considered for descending thoracic aorta aneurysms >60mm diameter. (Class
IIa; Level of evidence B).
• In elective thoracic endografting cases when it is planned to intentionally cover
the left subclavian artery, in patients at risk of neurological complications, preventive left subclavian artery revascularisation should be considered. (Class IIa;
Level of evidence C).
Switzerland AG 2023
E. S. Debus, R. T. Grundmann, Evidence-based Therapy in Vascular Surgery,
https://doi.org/10.1007/978-3-031-47397-5_4
69© The Author(s), under exclusive license to Springer Nature
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• In patients with ruptured descending aortic aneurysm, endovascular repair should
• In emergency ruptured descending thoracic aortic aneurysm in patients with a
These guidelines recommend for treatment of thoracoabdominal aortic aneurysms
(TAAA) [1]:
• Open or endovascular treatment should be considered for patients at low to mod-
• In open type I, II and III TAAA surgery, extracorporeal techniques allowing dis-
• In patients with extensive TAAA (type I, II, III) undergoing open repair, cerebro-
• An integrated approach with optimisation of mean and distal aortic arterial pres-
• For thoraco-abdominal aneurysm repair, in patients unt for open repair, an
• For thoraco-abdominal aneurysm repair in patients unt for open repair with
• Centralisation of endovascular repair of thoraco-abdominal aortic aneurysm in
4 Descending Thoracic Aortic Aneurysms (DTAA) and Thoracoabdominal Aortic…
be the rst treatment option when the anatomy is appropriate. (Class I; Level of
evidence B).
patent left mammary to coronary bypass or with a dominant or single left vertebral artery, left subclavian artery revascularisation should be performed prior to
left subclavian artery coverage (Class I; Level of Evidence C).
erate surgical risk, with an atherosclerotic or degenerative TAAA of 60mm or
larger diameter, rapid aneurysm enlargement (> 10 mm/year) or aneurysmrelated symptoms. (Class IIa; Level of evidence C).
tal aortic and organ perfusion should be considered to reduce ischaemic complications, especially in extensive aneurysms requiring prolonged cross clamping
time. (Class IIa; Level of evidence C).
spinal uid (CSF) drainage should be considered as a measure to decrease the
risk of neurological decit. (Class IIa; Level of evidence B).
sure, moderate hypothermia, neuromonitoring, and reimplantation of intercostal
arteries should be considered to protect the spinal cord during thoraco- abdominal
aortic aneurysm (Class IIa; Level of Evidence C).
endovascular procedure should be considered. (Class IIa; Level of evidence C).
aortic anatomy unfavourable for a branched/fenestrated endograft, a hybrid
approach should be considered. (Class IIa; Level of Evidence C).
dedicated high volume centres may be considered. (Class IIb; Level of evidence C).
4.1.2 Clinical Practice Guidelines oftheSociety forVascular
Surgery (SVS)
Important recommendations are [2]:
• In patients who could undergo either technique [open, OR or TEVAR] (within
the criteria of the device’s instructions for use), we recommend TEVAR as the
preferred approach to treat elective descending thoracic aorta (DTA) aneurysms,
4.1 Guidelines
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given its reduced morbidity and length of stay as well as short-term mortality.
Level of recommendation: Grade 1 (Strong), Quality of Evidence: A (High).
• We recommend TEVAR in asymptomatic patients with a descending thoracic
aortic aneurysm (TAA) when the maximum aneurysm diameter has exceeded
5.5cm in low-risk patients with favourable aortic anatomy. Level of recommendation: Grade 1 (strong). Quality of evidence B (moderate).
• We suggest using higher aortic diameter thresholds for TEVAR in patients
deemed to have a particularly high risk of death, renal failure, or paraplegia from
the procedure, where the benet of treatment is lower than the risk posed by the
natural history of the TAA.Level of recommendation: Grade 2 (Weak), Quality
of Evidence: C (Low).
• We recommend TEVAR in patients with IMH (intramural haematoma) or pene-
trating aortic ulcer (PAU) who have persistent symptoms or complications or
show evidence of disease progression on follow-up imaging after a period of
hypertension control. Level of recommendation: Grade 1 (Strong), Quality of
Evidence: B (Moderate).
The natural history of and indications for repair in patients with PAUs are controversial, but they have been found in one series to grow 2mm/year in their maximal
aortic size and length while growing an average of only 1.2mm/year in depth. The
presence of symptoms, an associated IMH, and an increase in pleural effusion
appear to be risk factors for complications. Treatment with TEVAR is indicated for
patients who are symptomatic despite best medical therapy or have an increase in
pleural effusion. The threshold for intervention for asymptomatic patients is also
controversial. According to one study, PAU depth>10mm and diameter>20mm
are risk factors for progressive disease.
Practice Statement: In the absence of clear and widely accepted parameters, the
decision to intervene in asymptomatic patients with IMH and PAUs should be individualized. Asymptomatic patients treated for PAUs in the setting of a maximal
aortic diameter<5.5cm or with PAUs <10mm deep or<20mm in diameter need
further study.
• We suggest TEVAR for symptomatic mycotic/infected TAAs as a temporizing
measure, but data demonstrating long-term benet are lacking. Level of recom-
mendation: Grade 2 (Weak), Quality of Evidence: C (Low).
• For elective TEVAR of a TAA where coverage of the LSA (left subclavian artery)
is necessary for adequate stent graft seal, we suggest preoperative or concomitant
LSA revascularization. Level of recommendation: Grade 1 (Strong), Quality of
Evidence: B (Moderate).
• We recommend nonionic, hypoosmolar contrast material with attempts at mini-
mizing intra-arterial contrast agent use, especially in patients at high risk for
contrast-induced nephropathy. Level of recommendation: Grade 1 (Strong),
Quality of Evidence: B (Moderate).
• We recommend pre-emptive SMA (superior mesenteric artery) stenting with a
balloon-expandable stent in cases of >50% stenosis of the SMA in the following
conditions: before or after CA (celiac artery) coverage or encroachment, with
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4 Descending Thoracic Aortic Aneurysms (DTAA) and Thoracoabdominal Aortic…
TEVAR that is encroaching on the SMA origin, or in any patient otherwise con-
sidered at high risk for post-TEVAR mesenteric ischemia. Level of recommenda-
tion: Grade 1 (Strong), Quality of Evidence: B (Moderate).
• In anticipation of high risk for CA territory ischemia (nonvisualization of CA
collateral branches by CTA or dedicated SMA angiography), we recommend
open or endovascular revascularization of the CA before TEVAR.Level of rec-
ommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate).
• Practice Statement: Brachiocephalic access for TEVAR device delivery may be
acceptable in situations in which transfemoral or iliac access is not available.
However, more data are required to determine whether carotid-axillary artery
access for delivery of a thoracic endograft is associated with increased
complications.
• We recommend TEVAR over open repair for the treatment of ruptured DTA
when it is anatomically feasible. Level of recommendation: Grade 1 (Strong),
Quality of Evidence: B (Moderate).
4.1.3 ACC/AHA Guideline fortheDiagnosis andManagement
ofAortic Disease
Important recommendations are [3]:
• In patients with intact descending TAA, repair is recommended when the diam-
eter is ≥5.5 cm. (Class of recommendation [COR] 1; Level of evidence
[LOE] B-NR).
• In patients with intact descending TAA and risk factors for rupture (Table4.1),
repair may be considered at a diameter of <5.5cm. (COR 2b; LOE B-NR).
• In patients at increased risk for perioperative morbidity and mortality (Table4.2),
it may be reasonable to increase the size threshold for surgery accordingly. (COR
2b; LOE B-NR).
Recommendations for endovascular versus open repair of descending TAA:
• In patients without Marfan syndrome, Loeys-Dietz syndrome, or vascular Ehlers-
Danlos syndrome, who have a descending TAA that meets criteria for interven-
Table 4.1 Risk factors for aortic rupture among patients with descending TAA [3]
High-risk features for rupture
• Aneurysm growth of ≥0.5cm/year
• Symptomatic aneurysm
• Marfan, Loeys-Dietz, or vascular Ehlers-Danlos syndrome, or heritable thoracic aortic
disease
• Saccular aneurysm
• Female sex
• Infectious aneurysm
4.2 Results
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Table 4.2 Patient characteristics associated with increased perioperative morbidity and mortality
after open and endovascular repair of descending TAA [3]
Open Surgical Repair Endovascular Repair
Advanced age
Preoperative renal insufciency (stage 3 or greater CKD)
or hemodialysis
COPD and FEV1≤50% predicted Pulmonary disease
Previous stroke Need for iliac access
CKD chronic kidney disease, COPD chronic obstructive pulmonary disease, FEV1 forced expiratory volume in 1s, TAA thoracic aortic aneurysm
Thoracoabdominal aortic aneurysm
extent
Zone 1/2 landing for thoracic stent
graft
73
tion and anatomy suitable for endovascular repair, TEVAR is recommended over
open surgery. (COR 1; LOE B-NR).
• In patients with a descending TAA that meets criteria for repair with TEVAR,
who have smaller or diseased access vessels, considerations for alternative vascular access are recommended. (COR 1; LOE B-NR).
• In patients with a descending TAA that meets criteria for intervention, who have
anatomy unsuitable for endovascular repair, and who are without signicant
comorbidities and have a life expectancy of at least 10years, open surgical repair
is reasonable. (COR 2a; LOE B-NR).
4.2 Results
4.2.1 Meta-Analyses andSystematic Reviews
4.2.1.1 Open vs. Endovascular Repair ofThoracic Aortic Aneurysms
The rst systematic review to investigate two-armed studies looking only at elective
endovascular stent grafting versus open surgical repair for treatment of chronic arch
or descending thoracic aortic aneurysms was published by McCarthy et al. [4].
Other reviews also included dissections or ruptures. Five comparative cohort studies
with 3955 endovascular stent graft procedures and 21,197 open surgical repairs
(ORs) were the basis. Meta-analysis of unadjusted short-term (30-day) all-cause
mortality favoured the endovascular procedure (odds ratio 0.75). Sensitivity analysis of four studies including only descending aortic aneurysms showed no signicant differences, with moderate heterogeneity. Meta-analysis of adjusted short-term
all-cause mortality favoured TEVAR (odds ratio 0.71), without heterogeneity.
Longer-term survival (beyond 30 days) from all-cause mortality favoured OR in
larger studies and TEVAR in smaller studies. Freedom from reintervention in the
longer-term favoured OR.Studies reporting short-term non-fatal complications suggested fewer events following TEVAR.The authors concluded that OR is better for
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4 Descending Thoracic Aortic Aneurysms (DTAA) and Thoracoabdominal Aortic…
long-term survival and avoidance of reintervention; conversely, TEVAR is better in
terms of short-term outcome.
4.2.1.2 Open Repair ofThoracic Aortic Aneurysms
Khan etal. [5] evaluated in a single-arm meta-analysis the results of a contemporary
series of open repair of TAAA and DTA in terms of operative and long-term mortality, and postoperative complications. 54 observational studies with 12,245 patients
met inclusion criteria and were included in the meta-analysis. The pooled operative
mortality was 10.4% (95% condence interval [CI], 8.3–12.8): 6.6% (95% CI,
3.7–11.6) for DTA and 10.5% (95% CI, 7.5–14.5) for TAAA.The pooled incidence
rate of late mortality was 0.6% per person-year. Pooled rates for postoperative outcomes were 4.9% for stroke; 5.7% and 3.0% for permanent and temporary spinal
cord injury, respectively; 13.2% for renal failure; 23.3% for respiratory failure; and
2.7% for myocardial infarction. Cerebrospinal uid (CSF) drainage was associated
with lower operative mortality. Ruptured aneurysms were associated with higher
mortality. The data indicate that open repair of these aneurysms is still associated
with a considerable risk for operative death and perioperative complications.
4.2.1.3 Spinal Cord Ischaemia After Open andEndovascular Repair
An inclusive contemporary analysis of spinal cord injury (SCI) rates in patients
undergoing aneurysm repair and the factors associated with complications has been
performed by Gaudino etal. [6]. 169 studies (22,634 patients) from 2008 to 2018 on
repair of descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) were pooled in this meta-analysis. The primary outcome was permanent SCI.Secondary outcomes were temporary SCI, operative mortality, long-term
mortality, postoperative stroke, and cerebrospinal uid (CSF) drain-related complications. The pooled rate of permanent SCI was 4.5%; 3.5% for DTA and 7.6% for
TAAA repair, 5.7% for open repair and 3.9% (95% CI, 3.1–4.8) for endovascular
repair. The pooled rates for operative mortality, late mortality at a mean follow-up
of 5.0years, stroke, and temporary SCI were 7.4%, 1.0%, 4.2% and 3.7%, respectively. The pooled rates for severe, moderate, and minor CSF-drain related complications were 5.1%, 4.1%, and 3.6% respectively. Despite improvement, both open
and endovascular aneurysm repair remain associated with a substantial risk of permanent SCI.The risk is greater for TAAA repair, especially extent II, III, and V.
A second meta-analysis has been performed for the occurrence of spinal cord
ischaemia after endovascular treatment of TAAA by Pini etal. [7]. A total of 27
studies with 2333 patients were included in this meta-analysis. The pooled rate of
SCI was 11%. For extent I, II, III and V TAAA the pooled SCI rate was 13%, for
extent IV TAAA the pooled SCI rate was 6%. A staged TAAA-endovascular repair
approach was used in 20 studies and a nonstaged approach in 8 (1 study had included
both). A lower rate of SCI was seen with a staged approach than with a non-staged
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approach (9% vs. 18%; p=0.02). Symptomatic CSF drainage was associated with
a similar pooled SCI rate compared with prophylactic CSF drainage (10% vs. 10%).
The pooled permanent SCI rate was 6% (6% for extent I, II, III and V TAAA; 3%
for extent IV TAAA). The pooled 30-day mortality rate was 7%, with a similar incidence for the staged and nonstaged approaches (6% vs 9%, respectively). The
authors concluded that for endovascular treatment of TAAA, the staged (two-stage)
approach is likely to be associated with a lower SCI rate. The overall efcacy of
CSF drainage could not be denitively assessed.
Zhang etal. [8] performed a systemic review and meta-analysis to compare the
association between prophylactic CSFD vs non-CSFD in preventing spinal cord
ischemia after thoracic endovascular aortic repair for aneurysm and dissection. A
total of 34 studies of 3561 patients (2671 with TAA or TAAA and 890 with type B
AD) were included. In the total population, the SCI rate after TEVAR with prophylactic CSF drainage was 4.45%, without drainage 3.18%. In the dissection group,
the SCI rate after TEVAR with prophylactic CSF drainage was signicantly lower
than in the aneurysm group with CSF drainage (1.8% vs. 5.73%; p < 0.0001).
Furthermore, for aortic dissections, the SCI rate was not different in TEVAR with
and without prophylactic CSF drainage. The same was true for patients with
TAA.However, in patients with TAAA and TEVAR, the rate of SCI was signicantly lower with routine CSF drainage than in patients with selective drainage
(p=0.04). This meta-analysis has shown that SCI occurs more often after TEVAR
for aortic aneurysms than for AD. Routine prophylactic CSFD, compared with
selective CSFD, was associated with a lower rate of postoperative SCI after TEVAR
for TAAAs. No signicant association was found between the SCI rate and routine
prophylactic CSFD for patients undergoing TEVAR for isolated TAA or AD.
4.2.1.4 Stroke Rate After Endovascular Repair ofTAA
Karaolanis etal. [9] performed a systematic review and meta-analysis to assess the
stroke rates after thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysms and/or dissections. 43 studies (5764 patients) were identied. Overall, the pooled stroke rate was 4.4%, and 1.8% for TBAD in 12 studies.
The incidence of stroke after coverage of the left subclavian artery (LSA) during
TEVAR was 5.97% and was reported in 19 studies. The pooled stroke rate for the
group of patients with LSA coverage and prior revascularization was 2.81% in 18
studies. For the group of patients with LSA ostial coverage without revascularization reported in 15 studies, the pooled stroke rate was 11.83%. If TEVAR was performed within or distal to zone ≥3, without coverage of LSA, the pooled stroke rate
was 3.15%. These ndings support the recommendation by the Society for Vascular
Surgery, which has recently suggested preoperative or concomitant LSA revascularization in cases of TEVAR for which LSA coverage is necessary for an adequate
stent graft seal (grade 1; quality of evidence B).
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