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7 Device Variations

The main anatomical feature that limits the role of

currently available devices is the quality and length of the

infrarenal aortic neck. This is because the fabric cannot be

placed above the renal arteries without occluding them.

The aorta at the level of the renal arteries is much less

prone to aneurysmal dilation and it is therefore an

attractive site to place the sealing stent of an endograft.

Renal blood ﬂow may be retained by manufacturing holes

or fenestrations in the fabric of the sealing stent.

Fenestrated stent-grafts (Fig. 10) are now available

commercially and are in widespread use. The locations of

the fenestrations are carefully planned from thin-slice CT

data and these pre-planned fenestrations are manufactured

to be at the correct height and correct position on the

circumference of the graft. The endovascular procedure

then involves releasing the stent-graft in vivo and ca-

theterising the target vessels transfemorally from within

the stent-graft. Stents are then placed within the ostia of

the target visceral vessels as experience has taught us that

renal artery occlusion may occur with un-stented fene-

strations due to partial shuttering of the vessel ostia by the

fabric of the stent-graft. With the bespoke nature of

fenestrated devices a 6 week manufacturing time is

Fig. 11 Pre- and post-

procedural volume-rendered CT

images of a type IV TAAA

treated with a Zenith branched

aortic stent-graft (Cook)

Fig. 10 Pre- and post-

procedural volume-rendered CT

images of a juxtarenal AAA

treated with a Zenith fenestrated

aortic stent-graft (Cook)

144 A. England et al.

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required and this limits the utility of fenestrated devices in

emergency circumstances such as ruptured/leaking aneu-

rysms. It is important that the fenestrated vessels emerge

from non-dilated aorta and it is essential that the graft is

opposed to the aortic wall at the branch points in order to

prevent endoleaks.

Fenestrated stent-grafts are not suitable if the fabric of

the stent-graft does not abut the aortic wall at the level of

the visceral arteries. This is common in thoraco-abdominal

aortic aneurysms (TAAs) and in these situations custom

made stent-grafts with side branch protrusions can be used

(Chuter et al. 2001; Tse et al. 2004). The idea is that the

stent-graft side branches will provide a bridge to reduce

the distance from the main body to the visceral artery

oriﬁce. Covered stents are inserted through the branches

and help achieve a better seal due to a longer overlap zone

intended to minimise endoleaks (Fig. 11). Branched devi-

ces can be made with preloaded angiographic catheters

and wires for easier cannulation of the visceral vessels.

Branched endografts have also been used in the treatment

of aortic arch aneurysms to preserve the great vessels and

in common iliac arteries to preserve the internal iliac

artery (Abraham et al. 2003).

Preservation of at least one internal iliac artery is

strongly desired during infrarenal AAA repair. Occlusion

of both internal iliac arteries carries a risk of colonic and

neurological sequelae in addition to erectile dysfunction

and buttock claudication. An iliac branch device (IBD)

includes a short branch which is located just above the

ostium of the internal iliac artery and a bridging stent is

then tracked into this from the opposite femoral artery.

If this is part of endovascular repair of an aorto-iliac

aneurysm then the procedure will ﬁnish with deployment

of a bifurcated aortic stent-graft (Fig. 12). If bilateral

common iliac artery aneurysms are present and both

internal iliac arteries are patent, we would recommend

preserving one internal iliac artery with an IBD and accept

the loss of the opposite internal iliac artery by embolisa-

tion with coils or a vascular plug.

Extending the proximal seal zone in order to facilitate

endovascular repair of a patient with a short proximal neck

is also achievable using a chimney or snorkel technique.

In this situation covered peripheral stents are deployed in

the visceral branches and will run alongside the main aortic

endograft following its deployment. Debate exists regarding

the role of chimney endografting and many believe that

Fig. 12 Pre-procedural CT MIP

image of a right common iliac

artery aneurysm (a). In order to

preserve blood ﬂow through the

internal iliac artery the aneurysm

was excluded using an iliac

branched device (b). IBDs can be

used for isolated common iliac

artery aneurysms or alongside a

standard infrarenal stent-graft

when faced with a coexisting

AAA (c)

Endovascular Abdominal Aortic Aneurysm Repair 145

https://t.me/med1917

these techniques are only indicated for an acute aneurysm

where time constraints preclude the use of a fenestrated or

branched endograft.

8 Device Improvements

Angulation of the proximal aortic neck has been associated

with adverse outcomes after EVAR. For many patients with

severe angulation of the aortic neck this will render them

ineligible for conventional infrarenal EVAR. The majority

of commercially available devices recommend excluding

patients with signiﬁcant aortic neck angulation. In order to

expand the use of EVAR for patients with disadvantaged

aortic necks the newer Endurant (Medtronic, Santa Rose,

CA) and Aorﬁx (Lombard Medical Technologies, Temple,

AZ) devices now have regulatory approval for use in more

angulated aortic necks. The Endurant can be used up to and

including 60° and the Aorﬁx is the only device approved for

use in aortic necks up to 90°.

The treatment of short aortic necks is still a challenge.

Intraoperative device repositioning is one option for

ensuring that all of the available aortic neck is used by the

stent-graft whilst limiting the possibility of coverage of a

renal artery ostium. The ability to reposition a device after

partial deployment is now a reality. The Gore Excluder

device (W.L. Gore and Associates, Flagstaff, AZ) is now

available on the C3 repositionable delivery system. The

option of repositioning the stent-graft can allow the operator

the greatest possible chance of using all of the available

aortic neck. Other devices have been designed with the

option to reposition and include the Anaconda stent-graft

(Vascutek Terumo, Ann Habor, MI).

A lower proﬁle delivery system seeks to remove access

issues and allow a shift to a mainly percutaneous approach.

When using a lower proﬁle system there will also be

improvements in delivery control for stent-graft deploy-

ment. Currently, there are two new low proﬁle (14 F)

EVAR devices, the Incraft (Cordis Corp, Miami, FL) and

European approved Ovation (Trivascular Inc., Santa Rosa,

CA). Concerns have arisen regarding the limitations of low

proﬁle devices and their overall effect on the long-term

durability of EVAR. However, if totally percutaneous

EVAR procedures are to become routine practice then it

may be necessary to consider using devices loaded on to a

lower proﬁle delivery system.

At the moment there is no perfect EVAR device avail-

able for implantation. In some areas AAA research has also

focused on treating the aneurysm sac by the injection of

polymers and elastomers. In the Endologix Nellix system

(Endologix, Irvine, CA) two polymer PTFE endobags are

inserted and seek to freeze the aneurysm sac and prevent

any further morphological changes. Thirty-four patients

have been successfully treated and approval for use in

Europe is expected in 2012. Suggested advantages of the

Nellix system are the removal of the possibility of type II

endoleaks and aneurysms can be treated with no infrarenal

aortic necks. Others have attempted to ﬁll the aneurysm sac

with polymers whilst occluding the aortic lumen (Uﬂacker

and Brothers 2006; Bosman et al. 2010). Early reports have

been conﬁned to experience in animal models. Ulﬂacker

and Brothers reported their experience in swine which did

result in successful aneurysm exclusion. They did, however,

conclude that two cases developed spinal cord ischaemia

perioperatively.

9 Evidence

The most important sources of evidence concerning EVAR

are the UK EVAR trials—EVAR 1 and EVAR 2. These two

multi-centre randomised controlled trials began in

September 1999. The EVAR trial 1 (Greenhalgh et al. 2004)

randomised patients with infrarenal AAAs of at least 5.5 cm

to either EVAR or open surgical repair (OSR). All patients

were aged 60 years or older, deemed ﬁt for OSR and

anatomically suitable for EVAR. Between September 1999

and December 2003, 1,082 patients were randomised

(EVAR = 543; OSR = 539). The 30-day mortality data

showed a signiﬁcant advantage in favour of EVAR 1.7

versus 4.7%. Complications were higher in the EVAR

group (9.8 vs. 5.8%) and 10 (1.8%) patients required con-

version to OSR within 30-days. All-cause mortality was

similar for both procedures by 4 years (28%), however a 3%

difference in aneurysm-related mortality, in favour

of EVAR remained (4 vs. 7%) (EVAR Trial Participants

2005a). Post-operative complications were more frequent

for EVAR patients (41 vs. 9%) but this had a negligible

impact on health-related quality of life (HRQL), which was

similar for both procedures. The long-term results revealed

that the beneﬁt of a lower aneurysm-related mortality for

EVAR was eventually lost due to a higher incidence of fatal

ruptures in the EVAR group (UK EVAR Trial Investigators

et al. 2010a). New complications were still occurring up to

8 years after treatment. As a result the long-term EVAR

data concluded that there were consistently higher rates

of complications and reinterventions for EVAR when

compared to OSR and as a result EVAR is a more costly

treatment option.

The EVAR 2 trial was designed to investigate the role of

EVAR in patients deemed unﬁt for OSR, this was originally

perceived to be the role for EVAR (EVAR Trial Partici-

pants 2005b). The EVAR 2 trial recruited 404 patients, aged

60 years or older, with AAA C 5.5 cm and anatomically

suitable for EVAR but not ﬁt for OSR. These patients were

randomised to EVAR with best medical therapy or best

146 A. England et al.

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medical therapy alone. The 30-day operative mortality for

the EVAR group was 7.3%, higher than in the EVAR 1 trial.

The 4 year data from this trial show an overall mortality of

64% with no signiﬁcant difference in mortality rates either

for aneurysm-related or for any causes. This trial did not

demonstrate a survival beneﬁt for EVAR in patients unﬁt

for OSR and endovascular repair was costly and did not

improve HRQL. With long-term follow-up there is a beneﬁt

from EVAR in terms of a lower aneurysm-related mortality

for EVAR (3.7 vs. 10.9 deaths per person-years) (UK EVAR

Trial Investigators et al. 2010b). However no differences in

total mortality rates have been demonstrated, the beneﬁt of

the differences in aneurysm-related mortality are limited as

this cohort of patients have a limited life expectancy with

few surviving beyond 8 years. For unﬁt patients EVAR is

considerably more expensive especially when compared to

no intervention.

Similar results to EVAR 1 have been published by the

Dutch Randomised Endovascular Aneurysm Management

(DREAM) trial group (Blankensteijn et al. 2005). This

multi-centre randomised controlled trial compared open

repair with EVAR in 351 patients with AAAs of at least

5 cm who were suitable for both techniques. There was a

3.4% difference in 30-day mortality rates (1.2% EVAR,

4.6% OSR). As with the UK EVAR trials, there is a

persistent reduction in aneurysm-related deaths in the

EVAR group, however, no overall survival difference was

observed during the mid- and long-terms (De Bruin et al.

2010). By 6 years, higher incidences of complications and

reinterventions were still being reported in the EVAR group

when compared to OSR 39.6 versus 18.1%.

The more recent US OVER (Veteran Affairs Open vs.

Endovascular Repair) trial started recruitment in 2002

(Lederle et al. 2009). Eligibility included patients with

AAAs C 5.0 cm, or an associated iliac aneurysm with a

maximum diameter of at least 3.0 cm, or an AAA with a

maximum diameter of 4.5 cm but evidence of rapid

enlargement or an AAA with saccular morphology. In total

881 US veterans were recruited and EVAR was associated

with lower (0.5%) 30-day mortality than OSR (3.0%). This

survival advantage, unlike in other studies, was maintained

by 2 years (EVAR 7.0%, OSR 9.8%). The 30-day mortality

rates for both arms were lower than for both of the two

European trials (EVAR 1 and DREAM). These differences

in mortality may reﬂect the nature of a newer trial with

likely improvements in both EVAR and OSR procedures.

All-cause mortality rates although favouring EVAR at

2 years must be treated with some caution. All of the four

aneurysm-related deaths during follow-up were in the

EVAR group.

The latest RCT to report (French ACE trial) was originally

conceived in 1998 but because of funding problems only

ﬁnished recruiting in 2008 (Becquemin et al. 2011). This

multi-centre study randomised patients with AAAs C 5cm

who were deemed at low to moderate risk from OSR (cate-

gories 0–2 on the SVS/AVSS comorbidity score). A total of

316 patients were randomised, fewer than both the EVAR 1

and DREAM trials. The trial reported no signiﬁcant differ-

ences in30-day mortalitybetweenOSR andEVAR 0.6versus

1.3%. No survival differences were reported between OSR

and EVAR at 1 year (3.5 vs. 4.8%) and 3 years (13.3 and

13.7%). Reintervention was required in 24% of EVAR

patients by 3 years compared with 14% for OSR. The French

ACE study results are different in that OSR and EVAR (for

low- to moderate-risk patients) have similar risks in the early

and mid-term. This is contrary to the three RCTs already

discussed which have all favoured EVAR in terms of short-

term mortality. Even the large case-matched Medicare ana-

lysis (45,660 patients) showed a reduction of post-operative

mortality favouring EVAR (1.2 vs. 4.8%) (Schermerhorn

et al. 2008). Differences betweenthe ACE trial results and the

remaining EVAR mortality data can be attributed to numer-

ous factors whichmay includestudydesign, experienceofthe

centres and the overall national standards of care.

Three trials are currently recruiting or have recently

completed evaluating OSR and EVAR in patients with

ruptured aneurysms. The Amsterdam Acute Aneurysm

(AJAX) trial started in 2004 (Amsterdam Acute Aneurysm

Trial Collaborators 2006) and initially failed to show any

differences between techniques for ruptured AAAs.

Recruitment was extended twice and the study ﬁnally

completed in 2010, formal results have yet to be reported.

The Paris-based Endovasculaire versus Chirurgie dans les

Anevrysmes Rompus (ECAR) trial started in 2008 and aims

to recruit 190 patients, it is still recruiting and aims to report

a primary end-point of differences in 30-day mortality

(Desgranges et al. 2010). The larger UK Immediate Man-

agement of the Patient with Rupture: open versus endo-

vascular repair (IMPROVE) trial started in 2009 and aims

to recruit 600 patients also aiming for a primary end-point

of 30-day mortality (Powell et al. 2009). To date, the only

randomised trial to have completed and reported outcomes

of open surgery or endovascular repair in ruptured AAAs

was undertaken in Nottingham between 2002 and 2004

(Hinchliffe et al. 2006). Thirty-two patients were random-

ised and the primary outcome was again 30-day mortality,

this was higher than expected for EVAR (53%) but still

comparable to open surgery. The study suspended early and

the trialists concluded that larger multicentre studies are

needed to provide deﬁnitive level one evidence.

For small aneurysms, the European CAESAR (Com-

parison of Surveillance vs. Aortic Endografting for Small

Aneurysm Repair) trial recruited 360 patients all with

AAAs of 4.1–5.4 cm in diameter (Cao et al. 2011). The

CAESAR study failed to demonstrate any advantage of

early EVAR over surveillance. Thirty-day mortality rates

Endovascular Abdominal Aortic Aneurysm Repair 147

https://t.me/med1917

for EVAR were low (0.6%) with aneurysm-related mortal-

ity and rupture rates both being low and comparable

between the two groups. The study did raise concern that up

to 60% of surveillance patients will require treatment within

3 years and that 16% of these patients may lose suitability

for EVAR during this time. The US PIVOTAL (Positive

Impact of Endovascular Options for Treating Aneurysms

Early) trial recruited 728 patients with asymptomatic AAAs

between 4–5 cm in diameter (Ouriel et al. 2010). Early all-

cause mortality for both the early EVAR and surveillance

groups were equal (4.1%). Aneurysm-related deaths were

also equal (0.6%) with 31% of patients in surveillance

requiring treatment during the study period, signiﬁcantly

more (98%) of these interventions were achievable using

EVAR. The PIVOTAL trialists concluded that early EVAR

or surveillance are both safe treatment options for small

aneurysms with low rates of aneurysm rupture and related

deaths (0.6%). The study authors further emphasised that

these conclusions are based only on early data (mean

20 months) and that the low rupture rates in the surveillance

arm are likely to reﬂect strict adherence to a rigorous sur-

veillance programme.

There is currently no RCT evidence for the safety and

efﬁcacy of fenestrated and branched stent-grafts in the

treatment of AAAs. A US prospective fenestrated endo-

grafting trial enrolled 119 patients who were at high-risk

from OSR and unsuitable for conventional EVAR (O’Neill

et al. 2006). Thirty-day mortality rates were 0.8% with no

ruptures or conversions to open repair during follow-up.

79% of patients survived beyond 3 years and 10/231 (4.3%)

target vessels were lost. A smaller multi-centre US study

reported similar results to the trial by O’Neill et al. but only

recruited 30 patients (with more stringent inclusion criteria)

(Greenberg et al. 2009). The short to midterm experience of

fenestrated endografting have also been summarised in a

meta-analysis by Sun et al. (2006). In view of the limited

data surrounding fenestrated repair a UK-based registry

(GLOBALSTAR) is currently analysing outcome data in

order to provide further evidence on safety and efﬁcacy.

For branched stent-grafts experience is conﬁned to

observational reports from single centres. One of the largest

prospective studies of the endovascular treatment of thora-

coabdominal aneurysms was undertaken by Roselli et al.

who recruited 73 patients with TAAs who were deemed at

high-risk from open surgery (Roselli et al. 2007). Periop-

erative and 1 year mortality rates were 5.5 and 19%

respectively and these were considered by the authors to be

low considering the patients included. Reﬁnements to the

device, technique and patient selection are constantly

evolving and a full assessment of device durability is

required before the more widespread application of this

technology. The use of branched stent-grafts is not restric-

ted to the abdominal aorta. Branched devices are available

for use in common iliac artery aneurysms (IBDs) and are

intended to preserve antegrade ﬂow into the internal iliac

artery. A multi-centre European study compared 64 patients

treated with an iliac branched device (IBD) and 54 patients

treated by open surgery recently reported (Donas et al.

2011). The 30-day mortality rate for an IBD was 0.0%

compared to 5.5% for open surgery, the incidence of but-

tock claudication and colonic ischaemia were non-signiﬁ-

cantly higher for open surgery 5.9 and 2.0% versus 3.1 and

0.0% respectively.

10 Future Developments

Fenestrated endografting is currently limited by the expensive

nature of the devices and lengthy manufacturing times. There

has thus been a move towards developing simpler, ‘off-

the-shelf’ fenestrated stent-grafts. A further response to the

lengthy manufacturing time for fenestrated devices is the

option of physicians modifying commercially available devi-

ces prior to deployment (Starnes 2011). Physician modiﬁable

endografts (PMEGs)have beendescribedas atreatmentoption

for complex juxtarenal aneurysms wherethe physician can use

a diathermyinstrumentto burn customisedfenestrationswithin

the graft fabric prior to deployment. This technology is not

widelyavailableand neitheris outcome databased oncarefully

controlled clinical trials. There are also signiﬁcant additional

regulatory and potential medicolegal issues surrounding the

modiﬁcation of commercially available devices by physicians

before implantation.

The combination of metal and currently available fabrics

has resulted in cases of fabric degeneration with resulting

endoleaks. Alternative devices which do not rely on a fabric

mounted on a metallic frame are under evaluation. The

Multilayer Aneurysm Repair System (MARS) stent

(Cardiatis, Isnes, Belgium)is anuncovered stent whichis said

to allow for treatment of an AAA by modulating haemody-

namic ﬂow. The MARS stent is composed of abraided cobalt

alloy and seeks to modulate blood ﬂow patterns thereby

achieving physiological exclusion of the aneurysm but

preserving ﬂowto collaterals. Bymodulating haemodynamic

ﬂow the velocity outside of the MARS stent is reduced by up

to 90% and this creates organised thrombus within the

aneurysm sac while preserving laminar ﬂow to collateral

arteries (Chocron et al. 2011). Reports are conﬁned to

individual case series and formal clinical studies have yet to

report the full safety and efﬁcacy of the MARS stent.

There is concern regarding the repeated use of ionising

radiation and nephrotoxic iodinated contrast media during

surveillance. Attempts at lowering the radiation dose for a

CT scan generally result in an unacceptable increase in

image noise. Recent advances in the computational power

of modern CT scanners have led to new methods of image

148 A. England et al.

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noise reduction. Instead of CT images being generated by

traditional ﬁltered back projection (FBP) new adaptive

statistical iterative reconstruction (ASIR) algorithms have

been shown to maintain the diagnostic capability of CT

studies, when performed at low radiation doses (Silva et al.

2010). The ASIR algorithm corrects the imaging data by

subtracting out the noise and a preliminary phantom and

patient study reported dose reductions of up to 65% without

any signiﬁcant loss in image quality (Hara et al. 2009).

A study using ASIR for the imaging of suspected aortic

dissection reported a 29% decrease in radiation dose when

compared to standard FBP CT examinations and no quan-

titative reductions in image quality were demonstrated

(Cornfeld et al. 2011).

With modern CT technology it has become possible to

replace multi-phase single-energy CT acquisitions with one

dual-energy CT acquisition (Stolzmann et al. 2008). Dual-

energy CT data acquired during or following contrast

medium injection can be used to create virtual unenhanced

images to accompany the enhanced series from a single

acquisition (Numburi et al. 2010). Work by Numburi et al.

concluded that dual-energy CT acquisitions can reduce the

overall radiation dose per examination by around 31% when

replacing multi-phase CT acquisitions. Even with any sig-

niﬁcant reductions in the radiation dose for follow-up, the

high costs and iodinated contrast issues of CT are still likely

to draw clinicians away from routine post-EVAR CT.

With more complex endovascular procedures now

available there is an increasing need to accurately evaluate

3D aneurysm morphology before, during and after the

procedure. MDCT provides the opportunity for 3D review

both before and after the procedure but intraoperative

imaging has traditionally remained dependent on 2D

ﬂuoroscopy and angiography. With modern ﬂuoroscopy

systems the image-intensiﬁer is replaced with a ﬂat-panel

detector and as a result there is now the option of

acquiring intraoperative 3D images. C-arm cone-beam

computed tomography or DynaCT uses a ﬂat-panel ﬂuo-

roscopy unit to acquire and display 3D CT-like imaging

data. CT images acquired in this way are of a slightly

lower contrast resolution than an equivalent diagnostic

CT image. For endovascular aortic aneurysm repair CT

ﬂuoroscopy or DynaCT have three potential applications.

Acquisition of a 3D volume using the ﬂat-panel ﬂuoros-

copy system can be used to assess aneurysm morphology

and for stent-graft sizing (Nordon et al. 2010). This may

be useful if the procedure is being performed as an

emergency or if there is signiﬁcant lag time between the

standard preoperative CT scan and the implantation

procedure. 3D images can also be combined or fused with

the real-time two-dimensional ﬂuoroscopy and angiogra-

phy images. This technique can be used as a navigation

tool, similar to ‘road-mapping’, for device implantation

especially in complex aneurysms which may involve the

use of fenestrated and branched endografts (Dijkstra et al.

2011). Finally, at the end of the procedure a 3D CT vol-

ume can be acquired and this can provide valuable

information on successful aneurysm exclusion and the

presence of any other complications (Biasi et al. 2009).

A signiﬁcant development in image-guidance for EVAR

procedures will be the ability to navigate through the aorto-

iliac system using real-time 3D imaging techniques. Intra-

operative navigational devices have been used successfully

in other surgical disciplines including orthopaedics, neuro-

surgery and ear, nose and throat surgery. 3D real-time

navigation can be achieved by obtaining continual 3D

acquisitions during the procedure. This would be both dif-

ﬁcult and incur a high radiation dose if undertaken solely

using the ﬂat-panel ﬂuoroscopy unit. A more likely option is

to fuse preprocedural CT data with intraoperative ﬂuoros-

copy images. When this fused data is loaded into custom-

ised tracking, registration and navigation software, wires,

catheters and stent-graft delivery systems can be manipu-

lated under 3D guidance using combined data from the

preoperative CT scan and real-time ﬂuoroscopy imaging.

Using this system it may be possible to deploy endografts

without the need for iodinated contrast administration and

with a decrease in ﬂuoroscopy times.

Electromagnetic systems are becoming available which

can track the tips of the devices and instruments using small

detector coils. The path and trajectory of the device can be

viewed in real-time without the need for any real-time

imaging using ionising radiation. In the future it may be

possible to combine 3D navigation systems with steerable

robotic catheters. These have the potential to allow the safe

and accurate positioning of endovascular tools within the

aorta and its branches. However, there are limitations to the

currently available 3D navigation systems which rely on

the co-registration of CT data on the intraoperative

ﬂuoroscopy images. These systems fail to compensate for

any elastic organ or tissue deformations and assume that

anatomic structures and instruments are rigid. Additional

registration and tracking problems may arise from arterial

contractility and respiratory motion of the vessels (Wood

et al. 2005).

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152 A. England et al.

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Endovascular Repair of Thoracic Aortic

Aneurysms

H. Rousseau, J. Auriol, C. Lions, V. Benouaich, E. Grunenwald,

V. Chabbert, B. Marcheix, C. Cron, M. A. Marachet, and P. Otal

Contents

1 Introduction.......................................................................... 153

2 Indications for Treatment .................................................. 154

3 Technical Aspects ................................................................ 154

3.1 Devices................................................................................... 154

3.2 Pre-Procedural Planning ........................................................ 154

3.3 Stent Graft Insertion .............................................................. 155

4 Results ................................................................................... 157

4.1 Peri-Procedural Complications.............................................. 157

4.2 Post-Procedural Complications ............................................. 158

4.3 Late Complications................................................................ 160

5 Speciﬁc Indications .............................................................. 161

5.1 Type B Dissection ................................................................. 161

5.2 Traumatic Rupture................................................................. 164

5.3 Other Indications ................................................................... 164

6 Conclusions........................................................................... 164

References...................................................................................... 164

Abstract

Endovascular treatment of aortic disease has emerged as

an alternative mode of treatment that is particularly

attractive for patients with severe comorbidities who

would not be ideal candidates for open surgery. Actually,

short-term morbidity and mortality rates, of large series,

compare favorably with those from surgery, and stent-graft

placement is proving to be a safe, minimally invasive, and

effective treatment for thoracic aortic diseases. However,

although endoluminal interventions are minimally inva-

sive, they are associated with complications, as are

surgical methods. In this article, indications, technical

aspects, and results of endovascular TAA repairs will be

reviewed.

1 Introduction

Annually, thoracic aortic aneurysms (TAA) affect approxi-

mately six out of 100,000 persons and the descending

thoracic aorta is involved in about 40% of those cases

(Bickerstaff et al. 1982). Thoracic aortic aneurysms typically

occur in elderly heavy smokers with hypertension, coronary

artery and obstructive pulmonary diseases. Untreated

patients with large thoracic aortic aneurysms have a 2-year

mortality rate of over 70%, most deaths due to aneurysm

rupture (Crawford and DeNatale 1986).

Although reﬁnements in the surgical treatment of

thoracic aortic aneurysms has reduced the death and com-

plication rates over the past two decades (Kouchoukos and

Dougenis 1997; Saﬁ et al. 1998; Lawrence et al. 1999), they

are still between 1.5 and 26%, even in high-volume centres

with experienced staff (Lawrie et al. 1994; Coselli et al.

1996; Kouchoukos and Dougenis 1997).

During the past few years, new endovascular methods of

treatment for descending thoracic aneurysms have gone

through explosive technological developments. The proce-

dure uses a stentgraft to serve asablood ﬂow conduit through

H. Rousseau (&)  J. Auriol  C. Lions  V. Chabbert 

M. A. Marachet  P. Otal

Department of Radiology, University Hospital,

Rangueil, 1, Av. Jean Poulhes, TSA 50 032,

Toulouse Cedex 9, France

e-mail: rouseau.h@chu-toulouse.fr

V. Benouaich  E. Grunenwald  B. Marcheix  C. Cron

Department of Cardiovascular Surgery, University Hospital,

Rangueil, 1, Av. Jean Poulhes, TSA 50 032,

Toulouse Cedex 9, France

M. G. Cowling (ed.), Vascular Interventional Radiology, Medical Radiology. Diagnostic Imaging,

DOI: 10.1007/174_2012_581, Ó Springer-Verlag Berlin Heidelberg 2012

153

https://t.me/med1917

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