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292 Brinster et al.
In contrast, open repair of isolated descending thoracic aneurysms, in the modern
era, has been associated with a 2.6% and 2.7% incidence of neurologic deficits in
two recent studies from major centers (85,86).
Stent grafting offers several potential advantages in reducing the risk of
spinal cord ischemia (SCI). These advantages include the avoidance of an aortic
cross clamp, fewer episodes of hypotension, less bleeding, and an earlier emer-
gence from general anesthesia to allow detection and treatment of a neurological
deficit. Conversely, stent grafting may have the following disadvantages: requir-
ing more extensive aortic coverage to allow adequate sealing between endolumi-
nal graft and aorta, inability to reimplant intercostal arteries, and injury to
ileofemoral vessels that may provice flow to the anterior spinal artery through the
hypogastric and pelvic vascular plexus.
Identified risk factors for SCI following thoracic aortic stent grafting include:
previous AAA repair, long segment of thoracic aortic stent graft, mobile atheroma,
iatrogenic vascular injury, hemorrhage, and hypotension (84,87–90). The mecha-
nisms which contribute to post-procedural SCI after TEVAR are multifactorial. The
risk of SCI in patients with previous AAA repair may be explained by the destruc-
tion of pelvic and hypogastric arterial collateral to the anterior spinal artery. Extended
graft coverage, especially in the levels of T6 to T12, compromises the vertebral
levels that are known statistically to supply the anterior spinal artery. Hypotension
and hemorrhage contribute by decreasing the perfusion pressure to the spinal cord.
Techniques to reduce the risk of SCI from TEVAR include using lumbar CSF
drains and applying neurocerebral monitoring. The use of a lumbar CSF drain has
been shown in numerous studies to decrease the risk of SCI in open surgical thora-
coabdominal aortic aneurysm repairs and endovascular thoracic aortic aneurysm
and dissection stent graft repair (91–93). The use of neurophysiological monitoring
has been traditionally applied to detect intraoperative spinal cord ischemic changes
and allow immediate alterations in perfusion management to reverse insults. The
Table 5 Risk Factors for Spinal Chord Ischemia After Endovascular Stent Repair of
Descending Thoracic Aortic Aneurysm
Spinal cord
Report n ischemia (%) Recovery Risk factors
Gravereaux et al. (87) 53 3 (5.7) 1/3 AAA repair, Long graft
Mitchell et al. (88) 108 4 (3.7) 0/4 AAA repair, Aortic occlusion
Moon et al. (89) 18 1 (5.6) 0/1 AAA repair
Ellozy SH 84 3 (3.6) 1/3 Not described
J Vasc Surg 2003
Greenberg et al. (90) 25 3 (12.0) 2/3 Long graft
Cheung et al. (84) 75 5 (6.5) 3/5 AAA repair, Mobile atheroma
Vascular injury, Hemorrhage
Hypotension
Total 363 19 (5.2) 7/19 (37%)
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Endovascular Thoracic Aortic Stent Grafting 293
use of neurophysiological monitoring in endovascular treatment of the thoracic
aorta has been reported to also allow early detection and intervention to augment
spinal cord perfusion pressure to decrease the risk (94). A proposed algorithm to
manage the risk of spinal cord ischemia is demonstrated in Figure 12.
The risk of stroke in endovascular repair is approximately 3% to 9%, which
is similar to open repair (95). Therefore, stroke rates are 2–3 × higher than paraple-
gia rates for thoracic endografting. There are several possible reasons for this high
stroke risk. Endovascular placement of thoracic aortic stent grafts requires multiple
Figure 12 Proposed algorithm to manage the risk of spinal cord ischemia in patients under-
going endovascular stent repair of descending thoracic aortic aneurysms. Abbreviations:
AAA, abdominal aortic aneurysm; CSF, cerebrospinal fluid; LE, lower extremity; MAP,
mean arterial pressure; Rx, drug therapy; SEP, somatosensory evoked potential. Source:
From Ref. 84.
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294 Brinster et al.
wire manipulations in the aortic arch. These manipulations may contribute to stoke
risk by producing emboli. Other risk factors for stroke include history of previous
stroke and grade V atheroma of the aortic arch (129).
Stent Migration
In most series, stent migration has been relatively rare (ranging from 1% to 3%).
Early stent migration is usually a result of inadequate proximal or distal landing
zone length. If the landing zone is inadequate, the stent can be displaced into the
aneurismal sac, resulting in migration. Additionally, persistent type I endoleaks can
cause aneurismal sac enlargement, which then may displace the stent from its
apposition to the proximal or distal landing zone. Late stent migration is usually
related to either continued tortuous lengthening of the native aorta, resulting in stent
component separation, or continuous increases in native aortic landing zone diam-
eter, which eventually results in a “free floating” stent within the enlarging aorta.
FUTURE DIRECTIONS
Early reports have suggested the possible beneficial use of TEVAR in a number
of acute aortic syndromes involving the ascending aorta and arch. A very likely
and appropriate application of ascending aortic TEVAR has been the treatment of
isolated saccular aneurysms and pseudoaneurysms of the ascending aorta. These
successful ascending aortic TEVAR applications have been characterized by
limited coverage distances, normal aortic diameters proximal and distal to the
psuedoaneurysm, and a corresponding high predicted mortality rate from standard
redo open surgery. The present limitation of this therapy is the fact that thoracic
endovascular devices have been designed for descending aortic diameters and
lengths. Examples of treated catastrophic ascending aortic conditions have been
cannulation site pseudoaneurysms and ascending aortic suture line disruptions.
An acute proximal aortic presentation treated with adjunctive thoracic aortic
stent grafting has been acute type A dissection. Most reports utilizing TEVAR in the
setting of acute type A dissection revolve around the hybrid deployment of a
descending stent anchored at the distal aortic arch after standard open type A dissec-
tion repair. The theoretical rationale for this TEVAR application is the knowledge
that standard acute type A dissection repair is associated with an 80% to 100% rate
of residual descending aorta dissection. Therefore, an adjunctive stent procedure on
the distal arch and proximal descending aorta may allow improved “remodeling” of
the residual dissected thoracoabdominal aorta compared to standard acute type A
repair. Multiple investigators have reported on the adjunctive use of an aortic stent
graft in the descending thoracic aorta during repair of acute type A dissection and its
effect on aortic remodeling. Early reports by Fleck et al. (96) and Kato et al. (97)
described preliminary results using home-grown stent grafts. The largest series, by
Liu et al. (98), reported 36 consecutive patients with acute type A dissection treated
with total arch repair with a simultaneous antegrade deployment of a “stented
elephant trunk.” They demonstrated an obliteration rate of the false lumen in the
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Endovascular Thoracic Aortic Stent Grafting 295
distal thoracoabdominal aorta approaching 92%. Panos and coworkers (99) reported
on five patients undergoing similar surgical strategy using the Endofit endoluminal
stent graft (Endomed Inc., Phoenix, Arizona, U.S.A.) with complete obliteration in
two patients and partial obliteration in three patients.
At the University of Pennsylvania, we have attempted to alter the prognosis
and natural history of the residual type B dissection following acute type A dissec-
tion repair by stenting the distal aortic arch and descending thoracic aorta. We have
presented a method for simultaneous open repair of the aortic dissection and
antegrade “stented elephant trunk” stabilization of the descending aorta using tho-
racic aortic stent grafts (Fig. 4) (101). To date, nine patients have been treated with
this technique, with five patients (56%) demonstrating complete thrombosis and
stabilization of the false lumen in the entire aorta (Fig. 5). Two patients (22%) had
stabilization of the descending thoracic aorta with persistence of the false lumen in
the aorta beginning at the level of the celiac axis. Two patients (22%) had persistent
false lumen in the descending thoracic aorta. Paraplegia did not develop in any of
the nine patients. Other reports of similar combined open and aortic stent graft repair
of acute type A dissection demonstrated comparable results of false lumen
obliteration and prevention of distal aortic aneursymal remodeling (96–99).
Arch Hybrids
Conventional repair of atherosclerotic aortic arch aneurysm is technically
demanding, requiring CPB and deep hypothermic circulatory arrest. Despite
recent improvements in surgical technique, total arch repairs of large atheroscle-
rotic arch aneurysms still have significant morbidity and mortality (102–105). In
contrast to nonatherosclerotic aortic arches, large atherosclerotic saccular aneu-
rysms of the arch are extremely high risk for perioperative stroke, as this disease
is a grave marker of extensive arch and brachiocephalic atheromatous disease. In
this subset of high risk patients, even the most recent series indicate in-hospital
mortality rates ranging from 6.3% to 20%, with stroke rates up to 12%
(43,106–111).
Beginning with descending thoracic aortic aneurysms, endovascular stent
graft technology has evolved as a safe and effective treatment for various thoracic
aortic diseases (20,46,50,112–115). Because of the anatomical features of the
aortic arch, endovascular therapy of arch aneurysms remains a technical challenge
(130,131). Maintaining cerebral perfusion and eliminating embolic events during
deployment are crucial for optimal neurologic outcome. Limited to Europe and
Japan due to the availability of stent graft devices, small series of combined extra-
anatomical bypass of the great vessels with endovascular deployment of a stent
graft in the arch have been reported with promising results (102,116–121). With
FDA approval in 2005, the Gore TAG (W.L. Gore, Flagstaff, Arizona, U.S.A.)
thoracic endoprosthesis became available commercially in the United States.
Previously, these patients have been considered prohibitively high risk for
conventional open arch repair due to their comorbidities, including the atheroscle-
rotic burden in the arch and the associated high stroke risk.
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296 Brinster et al.
Thoracoabdominal Aneurysms
Thoracic aortic stent grafting has now been utilized in the treatment of elective
thoracoabdominal aneurysms (122,123). Although this advance has not been
applicable in acute catastrophic presentations such as rupture or secondary dissec-
tion, thoracoabdominal aortic applications will undoubtedly be utilized in the
future. These are complex procedures requiring branch artery revascularization.
Postoperative Pseudoaneurysms
Psueodaneurysms of the thoracic aorta are an excellent indication for TEVAR.
Most general series report a small subset of patients treated with TEVAR for
pseudoaneurysms of previous thoracic aortic suture lines. Technically, this urgent
aortic condition is eminently suitable for stent grafting, as either the proximal or
distal landing zone is usually within a previously placed Dacron graft, which is
ideal for stent deployment (132).
Mycotic Aneurysms
TEVAR has been applied to a broad range of thoracic aortic diseases with mycotic
or septic characteristics. These have included isolated mycotic aneurysms,
broncho-aortic fistulas, aorto-esophageal communications, and infected grafts
and stent grafts (124–126). In general, the effectiveness of TEVAR for “mycotic”
type indications has been poor in the long-term. However, there maybe a role for
thoracic aortic stent grafting in the setting of mycotic or infected thoracic aortic
diseases as a “bridge,” to “defuse” the potentially catastrophic situation, while
allowing the patient to recover sufficiently for a definitive procedure.
CONCLUSION
In summary, it is precisely in acute aortic events that application of TEVAR may
be most beneficial. Since traditional open surgical procedures for acute aortic
conditions have historically had a high morbidity and mortality, the application of
TEVAR to these pathologies may offer significant survival benefits. As device
technology improves and clinical experience expands, TEVAR applications are
also likely to expand.
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