Changing trends in management of thoracic aortic disease: where do we stand with thoracic endovascular stent grafts?

BACKGROUND

Descending thoracic aortic surgery is linked to a high morbidity and mortality. Thoracic endovascular stent grafts were designed to decrease perioperative risks, especially in patients with severe comorbidities. However, procedure-related complications and clinical outcomes remain ill-defined.

PATIENTS AND

METHODS

The authors' experience in 24 patients (mean age 63.3+/-25.4 years) from May 2001 to February 2004 is reported. The diagnosis was thoracic aneurysm in 10 patients, complicated penetrating aortic ulcer in six patients, blunt traumatic aortic rupture in four patients, complicated type B dissection in two patients, and aortoesophageal fistula and postoperative pseudoaneurysm in one patient each, respectively. Symptoms were present in 15 of 24 patients (62.5%). The decision to implant a thoracic endovascular stent graft was based on significant coinjuries in three patients, severe comorbidities in 16 patients and patient decision in five patients.

RESULTS

The mean operative time was 2.3+/-1.7 h and the mean number of stents per patient was 1.8+/-0.7. Six patients required coverage of the left subclavian artery without complications. A carotid-carotid bypass was required in two patients. In one patient, a thoracic endovascular stent graft was introduced through a 10 mm graft anastomosed to the distal descending aorta accessed through a video-assisted minithoracotomy. Perioperative complications were an arterial access problem in one patient and pneumonia in four patients. The primary success rate was 100%. An 82-year-old patient with a ruptured thoracoabdominal aneurysm died of multi-organ failure (4.1% hospital mortality). All 23 surviving patients were alive at 13.4+/-3.5 months. One patient required an additional procedure for recurrent hematemesis.

CONCLUSIONS

Thoracic endovascular stent grafts show excellent early results in well-selected cases. Extra-anatomical bypass or novel vascular access procedures increase the applicability of thoracic endovascular stent grafts. Meticulous follow-up is essential to identify and treat stent graft-related complications. Data on long-term outcomes are required before applying thoracic endovascular stent grafts to patients with a lower operative risk.