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Endovascular repair of the thoracic aorta


Authors: Grace J Wang, MD, Ronald M Fairman, MD
Section Editors: Gabriel S Aldea, MD, John F Eidt, MD, Joseph L Mills, Sr, MD
Deputy Editor: Kathryn A Collins, MD, PhD, FACS

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature rev iew current through: Apr 2020. | This topic last updated: May 03, 2018.

INTRODUCTION

Endovascular repair of the thoracic aorta, also referred to as thoracic endovascular aortic repair
(TEVAR), refers to a minimally invasive approach that involves placing a stent-graft in the thoracic
or thoracoabdominal aorta for the treatment of a variety of thoracic aortic pathologies. TEVAR
was initially used to provide treatment to patients who were not considered to be surgical
candidates, but it is now the preferred technique for treatment given the improved risk profile
compared with open thoracic aortic surgery. In this topic review, we principally discuss
endovascular repair of thoracic aortic aneurysm, but variations on the technique as it pertains to
other thoracic pathologies are also briefly reviewed.

The indications for, preparation, and issues related to thoracic endograft placement, follow-up,
and outcomes will be reviewed. Issues related to the management of thoracic aortic diseases
that might be treated using thoracic endovascular stent-grafts are discussed separately. (See
"Management of thoracic aortic aneurysm in adults" and "Management of acute aortic
dissection" and "Clinical features and diagnosis of blunt thoracic aortic injury" and "Overview of
acute aortic dissection and other acute aortic syndromes" and "Management of blunt thoracic
aortic injury".)

Anesthetic issues regarding endovascular aortic repair are reviewed separately. (See
"Anesthesia for endovascular aortic repair".)

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ANATOMIC CONSIDERATIONS

Aortic arch anatomy, extent of aortic arch disease (figure 1), and the available landing zones
dictate the nature of endovascular repair.

"Normal" thoracic aortic diameter varies according to location within the aorta and also with age,
gender, and body habitus [1-3]. Average normal diameters of the thoracic aorta identified on
imaging (computed tomography, magnetic resonance) are given elsewhere. (See "Clinical
manifestations and diagnosis of thoracic aortic aneurysm", section on 'Definition of TAA'.)

Aortic anatomy — The aorta originates immediately beyond the aortic valve and ascends
initially, then curves, forming the aortic arch, and descends caudally adjacent to the spine. The
ascending thoracic aorta gives off the coronary arteries, and the aortic arch branches are
typically the brachiocephalic trunk (branches to the right common carotid and right subclavian
arteries), left common carotid, and left subclavian arteries; however, aortic arch anatomy can vary
(figure 2). The descending thoracic aorta provides paired thoracic arteries (T1-T12) and
continues through the hiatus of the diaphragm (figure 3A-B) to become the abdominal aorta,
which extends retroperitoneally to its bifurcation into the common iliac arteries at the level of the
fourth lumbar vertebra.

The abdominal aorta is a retroperitoneal structure that begins at the hiatus of the diaphragm and
extends to its bifurcation into the common iliac arteries at the level of the fourth lumbar vertebra
(figure 3B). It lies slightly left of the midline to accommodate the inferior vena cava, which is in
close apposition. The branches of the aorta (superior to inferior) include the left and right inferior
phrenic arteries, left and right middle suprarenal arteries, the celiac axis, superior mesenteric
artery, left and right renal arteries, possible accessory renal arteries, left and right gonadal
arteries, inferior mesenteric artery, left and right common iliac arteries, middle sacral artery, and
the paired lumbar arteries (L1-L4).

The common iliac artery bifurcates into the external iliac and internal iliac arteries at the pelvic
inlet (figure 4). The internal iliac artery, also termed the hypogastric artery, gives off anterior and
posterior branches to the pelvic viscera and also supplies the musculature of the pelvis. The
external iliac artery passes beneath the inguinal ligament to become the common femoral artery.

Landing zone classification — The thoracic aorta is divided into landing zones (zones 0 to 4) for
the purpose of describing the extent of endovascular coverage, which determines the need for
aortic debranching procedures (figure 5). For each of these, the endograft attachment site can
be described as below with the proximal attachment zone classified as Zone 0 to 5 and the

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distal attachment zone classified as Zone 4 to 11 [4]:

● Zone 0 – Proximal to the innominate artery origin


● Zone 1 – Distal to the innominate but proximal to the left common carotid artery origin
● Zone 2 – Distal to the left common carotid origin but proximal to the subclavian artery
● Zone 3 – ≤2 cm from the left subclavian artery without covering it
● Zone 4 – >2 cm distal to the left subclavian artery but within the proximal half of the
descending thoracic aorta (T6)
● Zone 5 – Starts in the distal half of the descending thoracic aorta but proximal to the celiac
artery
● Zone 6 – Celiac origin to the top of the superior mesenteric artery
● Zone 7 – Superior mesenteric artery origin, suprarenal aorta
● Zone 8 – Covers at least one renal artery
● Zone 9 – Infrarenal
● Zone 10 – Common iliac
● Zone 11 – External iliac

Spinal perfusion — The spinal cord is supplied by three major vessels arising from the vertebral
arteries in the neck, one anterior spinal artery and a pair of posterior spinal arteries, which
anastomose distally at the conus medullaris (figure 6). The anterior spinal artery supplies the
anterior two-thirds of the spinal cord. The thoracic spinal cord is particularly dependent on
radicular contributions to the anterior spinal artery. The artery of Adamkiewicz (Arteria Radicularis
Magna) is the most prominent thoracic radicular artery and can be found between the T9 to T12
level in the majority of individuals but can also be located above or below this level. The anatomy
of the spinal cord is discussed in more detail elsewhere. (See "Spinal cord infarction: Vascular
anatomy and etiologies", section on 'Vascular anatomy' and 'Minimizing spinal ischemia' below
and 'Spinal cord ischemia' below.)

INDICATIONS FOR ENDOVASCULAR AORTIC REPAIR

Endovascular repair of the thoracic aorta was initially used to provide treatment to patients with
thoracic aortic aneurysm who were not suitable candidates for open surgery. The pivotal trials of
stent-graft placement for the treatment of thoracic aortic aneurysm led to its approval by the US
Food and Drug Administration (FDA) in 2005 [5-10]. Endovascular repair of the thoracic aorta
has been increasingly used for other aortic pathologies, including blunt thoracic aortic injury,
aortic dissection, and penetrating aortic ulcer, among others [11,12]. Guidelines from major
medical and surgical societies emphasize an individualized approach when choosing

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endovascular repair, taking into account the patient's age and risk factors for perioperative
morbidity and mortality. Whether to choose an open or endovascular approach for specific aortic
pathologies is discussed in separate topic reviews. (See 'Thoracic aortic aneurysm' below and
'Other thoracic aortic pathologies' below.)

While there are no randomized trials directly comparing open and endovascular repair of the
thoracic aorta, observational studies suggest equivalent or better patient-important outcomes
with thoracic endovascular repair [13]. Benefits of endovascular relative to open repair include
avoidance of sternotomy and thoracotomy, no need to cross-clamp the aorta, less blood loss, a
lower incidence of end-organ ischemia, fewer episodes of respiratory dependency, and quicker
recovery [14].

Thoracic aortic aneurysm — Degenerative thoracic aortic aneurysms are classified depending
upon their proximal and distal extent as ascending aneurysm, arch aneurysm, descending
thoracic aneurysm, and thoracoabdominal aneurysm (figure 1) [1,15-18]. These categories help
to stratify the approach to surgical management. (See "Management of thoracic aortic aneurysm
in adults".)

Patients with thoracic aortic aneurysms, particularly large or expanding aneurysms, have an
overall poor prognosis. Survival is improved for open surgical repair compared with medical
therapy, and although there are few data comparing endovascular repair and medical
management, it is reasonable to assume that outcomes will also be better for endovascular
repair in those patients with indications for open surgery, since endovascular repair compares
favorably with open surgery. (See "Management of thoracic aortic aneurysm in adults".)

Although endovascular repair of infected aortic aneurysm is not the preferred treatment, it is an
option for patients who are poor surgical candidates [19-21]. These issues are discussed in
detail and summarized elsewhere. (See "Overview of infected (mycotic) arterial aneurysm".)

Other thoracic aortic pathologies — Because endovascular repair is associated with a


significant reduction in perioperative morbidity and mortality compared with open surgical repair,
an endovascular approach is increasingly being applied to a variety of thoracic aortic
pathologies, including blunt thoracic aortic injury, aortic dissection, aortic intramural hematoma,
and penetrating aortic ulcer, among others [11,12].

Blunt thoracic aortic injury — Traumatic aortic transection typically occurs with high-speed,
deceleration-type injuries at the level of the ligamentum arteriosum. Endovascular repair has
been associated with significantly lower perioperative morbidity and mortality compared with
open repair [22-24]. Systemic anticoagulation can be held during these cases if there is

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concomitant head injury [25]. However, long-term data regarding the longevity of stent repair in
this typically younger age group are not available. (See "Surgical and endovascular repair of
blunt thoracic aortic injury".)

Aortic dissection — The treatment of acute, uncomplicated aortic dissection is primarily


conservative, but intervention may be needed for those who develop complications. Treatment of
complicated Type B dissection with malperfusion has been successfully treated using
endovascular techniques and consists of covering the primary entry tear and re-expanding the
true lumen [26,27]. Assessment of the restoration of luminal flow to the true lumen can be
performed with the use of IVUS (intravascular ultrasound), which offers real-time information
regarding the true and false lumina throughout the cardiac cycle. Although thoracic devices have
been approved by the US FDA for the management of both acute and chronic dissection, there is
considerable uncertainty in terms of the role of thoracic endovascular aortic repair (TEVAR) in the
setting of chronic dissection, and further study is needed.

In the multicenter INvestigation of STEnt grafts in patients with type B Aortic Dissection (INSTEAD
trial), optimal medical therapy was compared with endovascular stent-graft placement [28,29]. At
one-year follow-up, no significant difference in all-cause mortality was found between the
groups. At five years, TEVAR in addition to optimal medical treatment was associated with
improved aorta-specific survival and delayed disease progression. A critique of the INSTEAD
trial was that the study was designed to evaluate patients with more chronic dissections (56
days in the stent-graft group versus 75 days in the medical management group). The ADSORB
study, a pending trial in Europe, will compare best medical management to stent-grafting for
patients with uncomplicated type B dissection presenting <14 days after symptom onset [30].
(See "Surgical and endovascular management of type B aortic dissection".)

Aortic intramural hematoma/penetrating aortic ulcer — These lesions are within the
spectrum of aortic dissection pathology, and endovascular treatment is similar to type B aortic
dissection, consisting of covering the intimal tear of any coexistent dissection to exclude the
aortic lesion. Although isolated penetrating ulcers are easier to cover with endovascular devices,
extensive intramural hematoma may be a contraindication to this approach. (See "Overview of
acute aortic dissection and other acute aortic syndromes".)

Aortoesophageal fistula — Aortoesophageal fistula is a life-threatening cause of upper


gastrointestinal bleeding that may be due to a variety of etiologies (eg, malignancy, thoracic
aneurysm, foreign body including aortic stent-graft) [31]. Endovascular stenting may be used as
a temporizing measure to prevent exsanguination and allow for fluid resuscitation [32,33].
Patients are at risk for graft infection if definitive esophageal repair is not performed. In one

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retrospective review, endovascular stent-grafting was performed within 24 hours of diagnosis in


83 percent of patients and was technically successful in 87 percent [32]. Open graft explantation
and resection and repair of the esophagus constitute definitive repair [34] and in this series was
able to be performed within one month of presentation in 11 percent of patients.

Contraindications — Endovascular repair of the thoracic aorta is contraindicated in patients who


do not meet the anatomic criteria required to place any of the available endografts. (See
'Planning TEVAR' below and 'Choice of endograft and endograft sizing' below.)

Whether young patients, typically those suffering traumatic aortic injury, who have an acceptable
risk for open surgery should undergo endovascular repair remains controversial. Surveillance
over an extended period of time exposes the patient to greater levels of cumulative radiation, and
long-term outcomes are unknown.

A relative contraindication to endovascular repair is the inability to comply with the required
follow-up surveillance. (See 'Postoperative endograft surveillance' below.)

THORACIC ENDOGRAFTS

Endovascular repair of thoracic aortic aneurysm is accomplished using a fabric-covered stent,


termed an endograft or stent-graft. Adoption of stent-graft technology by vascular surgeons has
been rapid, primarily related to preexisting experience and facility with the endovascular repair of
abdominal aortic aneurysm. (See "Endovascular repair of abdominal aortic aneurysm".)

Although there are variations from device to device, three components (delivery system, main
body, and extensions) are common to all endograft device systems. Thoracic endograft devices
are currently approved for treatment of descending thoracic aneurysms, penetrating aortic
ulcers, aortic intramural hematoma, descending (type B) thoracic aortic dissection [35,36],
residual descending thoracic aortic dissections, and traumatic aortic transection [37] in the
United States [38,39].

Thoracic endovascular devices for thoracic aortic repair are discussed in detail elsewhere.
These include (see "Endovascular devices for thoracic aortic repair"):

● TAG and cTAG


● TX2 and Alpha
● Valiant Thoracic Stent-Graft system
● Relay

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The degree of structural support varies from device to device. Proponents of designs that have
less metallic support structure claim the device is better able to adapt to changes in aneurysm
configuration over time. On the other hand, some physicians feel that fully supported endografts
are less prone to kinking and subsequent thrombosis. The curve of the proximal thoracic aorta
adds an additional challenge to achieving a design with adequate proximal fixation and seal.
The amount of radial support, which allows the endograft to withstand external compression,
must be weighed against the need for enough flexibility and conformability within the device to
navigate the proximal aorta and achieve a proper seal following deployment.

New endograft designs are continually being tested to enhance performance. Improvements
have focused upon smaller device and delivery profiles, more accurate deployment, improved
fixation systems, and perhaps most importantly, flexibility in managing challenging anatomy.
These improvements, along with increased operator experience, have led to improvements in
the short-term and long-term results of endovascular aneurysm repair and have expanded the
application of endovascular repair to many patients whose aortic anatomy was previously
deemed unsuitable.

PLANNING TEVAR

Choice of imaging — We prefer computed tomography angiography (CTA) of the chest,


abdomen, and pelvis, including the femoral arteries, and three-dimensional reformatting to
assess the aorta to appropriately size the diameter and length of the thoracic endograft. CTA
provides accurate information regarding the external and endoluminal diameter of the aorta at
the proximal and distal seal zones, the length of aortic coverage needed, the degree of
angulation and tortuosity of the aorta (which may identify the risk for endoleak [40]), identification
of important side branches, as well as characteristics of the lumen and wall of the aorta,
including thrombus burden and calcification.

Magnetic resonance angiography (MRA) can also be used, but MRA does not demonstrate
vessel wall calcification, which has implications for vascular access [41].

Aortoiliac evaluation — Imaging evaluation of the aorta involves measurement of the external or
endoluminal diameter of the aorta at the proximal and distal seal zones, identifying the length of
aortic coverage needed, the degree of angulation and tortuosity of the aorta, identification of
important side branches, as well as evaluating the characteristics of the lumen and wall of the
aorta, including thrombus burden and calcification. We use centerline measurements, which are
particularly useful for angled sections of the aorta, to evaluate for device length, but other

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methods are also used [42,43]. The angulation of the aorta often progresses with age as
atherosclerotic changes lead to lengthening and increased tortuosity, which adds to the difficulty
of accurate device deployment and obtaining an adequate proximal seal. In general, a 2-cm
length of normal diameter aorta is required to achieve a seal. Specific parameters for individual
devices are given in the instructions for use (IFU) for each device.

Suitable iliac artery morphology is also required for passage of the thoracic endograft. The iliac
arteries should have a minimal amount of calcification and tortuosity, and no significant
stenosis. Generally, a 7- to 8-mm external iliac artery should accommodate a 22 French sheath,
which is an approximately 24 French (8-mm) outer diameter. In one review, women were more
likely to require a low-profile device or conduit to allow placement of a device [44]. The
requirements for a specific device are found in the IFU. Once the diameter of the iliac and
femoral arteries and the degree of calcification/tortuosity are evaluated, a decision can be made
as to whether to proceed with transfemoral or alternative access. (See 'Vascular access' below.)

Zones of attachment — To exclude blood flow from a thoracic aortic aneurysm sac, the
endograft must provide an adequate seal where the endograft contacts the arterial wall
proximally at the aneurysm neck and distally, otherwise known as the landing zones. Compared
with endograft placement in the abdominal aorta, the high forces in the thoracic aorta require
longer seal zones (2 cm) to prevent displacement.

● Proximal – The proximal landing zone may abut or involve branch vessels of the arch,
namely the brachiocephalic trunk, left common carotid artery, and left subclavian artery.
When device deployment is performed close to or within the arch, the graft must closely
appose the "inner curve" of the arch. If the proximal end of the graft is oriented toward the
apex of such a curve, "bird-beaking" where the graft is not apposed to the aortic wall will
occur, increasing the risk of graft collapse, migration, and failure of aneurysm exclusion
[45-48]. With adequate preoperative planning, landing more proximally and debranching the
arch as needed can usually circumvent these issues. To achieve the 20-mm proximal seal
required and ensure that the graft will sit in close apposition to the inner curve of the arch,
debranching procedures using "hybrid" techniques can be performed, which essentially
"move" the branch vessels to a more proximal location, allowing coverage of the origins of
these vessels [49-51]. (See 'Arch vessel bypass' below and 'Landing zone classification'
above.)

● Distal – The distal seal zone also must be at least 20 mm in length. Typically, the celiac axis
is spared given the potential adverse consequences of coverage [52]. However, successful
cases of covering the celiac artery to gain an additional 25 mm in seal length have been

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reported in patients with a documented patent pancreaticoduodenal arcade with a low


incidence of mesenteric ischemia [53,54]. The need for the distal end of a
thoracoabdominal aneurysm repair to extend below the mesenteric artery necessitates an
alternative source of blood flow to the mesenteric and renal arteries before endografting to
avoid compromising their flow [51]. (See 'Visceral artery bypass' below.)

Choice of endograft and endograft sizing — Careful preoperative sizing and planning, along
with strict adherence to device-specific IFU, leads to the best outcomes. All approved endografts
have demonstrated short- and mid-term success in treatment of thoracic aortic aneurysms and
have also been used to treat other aortic pathologies. These devices can also be used to treat
aortic arch aneurysms following debranching procedures. (See 'Need for debranching
procedures' below.)

The larger thoracic aorta necessitates the use of larger-diameter stent-grafts compared with
those used for abdominal endovascular repair. Commercially available devices have endograft
diameters as small as 21 mm and as large as 46 mm, which allows endovascular repair of
native thoracic aortic diameters between 18 and 42 mm. Ten to 20 percent oversizing is
recommended for thoracic endografts, although oversizing should be limited to 10 percent for
patients with acute and subacute dissection. Excessive oversizing may lead to retrograde aortic
dissection, a potentially lethal complication of TEVAR [55,56].

Need for debranching procedures — Placement of the proximal or distal end of the device may
require covering important aortic side branches. Debranching procedures involve open surgical
vascular bypass to important vessels prior to thoracic stent-grafting placement [51].

Some groups have combined fenestrated or branched abdominal aortic endografts, or other
stents in the chimney/snorkel or periscope orientation with thoracic grafts, to avoid the need to
perform debranching procedures in the abdomen [57-66]; whether one approach is better than
another has yet to be determined [67]. In situ fenestration of the graft (using a needle, laser, or
other energy device) has been described, particularly in association with emergency surgery, to
avoid the need for left subclavian revascularization [68-70]. Single-branch stent grafts are
available in the context of feasibility and pivotal trials. Multi-branch stent-grafts are only available
via investigational device exemption trials. (See "Endovascular devices for thoracic aortic repair",
section on 'Advanced devices'.)

Arch vessel bypass — If the proximal landing zone involves any of the aortic arch vessels,
arch vessel bypass (eg, ascending aortic-innominate, ascending aortic-left common carotid, left
carotid-subclavian bypass) needs to be considered.

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Subclavian revascularization — Observational studies suggest that under most


circumstances, preemptive rather than expectant left subclavian artery revascularization does not
significantly alter outcomes when coverage of the left subclavian is deemed necessary [71-77].
However, for patients with a dominant left vertebral, hypoplastic right vertebral, or incomplete
circle of Willis, planned coverage of the left subclavian should be preceded by left carotid
subclavian bypass, as interruption of blood flow in these circumstances has been associated
with an increased incidence of stroke and paraplegia [78-83]. Flow to the left subclavian should
also be considered in patients with long-length thoracic aortic coverage and for patients with
prior abdominal aortic aneurysm repair.

Left subclavian artery (LSA) coverage may be needed to achieve a proximal seal in up to 40
percent of patients treated with thoracic endovascular aortic repair (TEVAR). Whether to routinely
revascularize the LSA preoperatively or manage the left extremity expectantly (ie, no preoperative
revascularization) remains controversial. A systematic review identified five studies [72-76] in
which LSA was performed during 1161 TEVARs, with 444 patients undergoing revascularization
[71]. Stroke rates were not significantly reduced for patients undergoing left subclavian
revascularization compared with no revascularization (odds ratio [OR] 0.70, 95% CI 0.43-1.14)
[71]. There were also no significant differences in rates of spinal cord ischemia with left
subclavian revascularization (OR 0.56, 95% CI 0.28-1.10) or death (OR 0.87, 95% CI 0.55-1.39).

Rarely, patients may develop debilitating arm claudication symptoms at a later date, at which
time an elective revascularization procedure can be performed. One review reported that only 4
percent of the patients who developed symptoms of upper extremity ischemia required
subsequent revascularization [84]. Thus, many advocate selective LSA revascularization.
Patients who should be considered for preoperative left subclavian revascularization include
those with a patent left inferior mammary artery-coronary bypass, dominant or isolated left
vertebral artery, or functioning left upper extremity dialysis arteriovenous access [85]. When
coverage of the left subclavian artery is needed, duplex ultrasound of the vertebral and carotid
arteries should be performed to determine the optimal procedure to restore left subclavian flow
(eg, carotid-subclavian bypass, subclavian-carotid transposition).

When left subclavian revascularization is needed, comparisons of carotid-subclavian bypass


and subclavian-carotid transposition have found no significant differences in stroke, spinal cord
ischemia, or mortality [75,86].

Carotid revascularization — For proximal landing zones that will cover the left common
carotid artery or brachiocephalic trunk, open, antegrade bypass from the ascending aorta or
carotid transposition can be performed, or alternatively, extra-anatomic bypass such as carotid-

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carotid bypass can be performed to avoid sternotomy [87-90].

Visceral artery bypass — Visceral ischemia can occur with coverage of the celiac axis, and
in general, we try to avoid celiac coverage. However, some reports have suggested that
collateralization through an intact pancreaticoduodenal arcade can allow for extension of the
distal seal zone to the level of the superior mesenteric artery (SMA) without physiologic
consequence [53]. In a literature review, coverage of the celiac axis during TEVAR for thoracic
aortic aneurysm without accompanying celiac artery embolization resulted in only three type II
endoleaks (table 1) among 72 patients, and these were successfully treated by coil
embolization. Another small study of TEVAR for Type B dissection confirmed the feasibility of this
approach.

Stenting to below the SMA or renal artery levels requires revascularization of these vessels via
open surgical bypass (debranching), or by using snorkel or chimney stents [91-93], or
specialized fenestrated or side-branched grafts [64,65,94,95]. Debranching procedures provide
blood flow to the visceral arteries via alternative vessels to allow coverage by the graft of the
visceral segment of the aorta [96,97].

Timing of bypass procedure — Debranching procedures are surgical bypasses that reroute
blood flow from the aorta to the target vessel.

For visceral debranching, the procedure is performed prior to endovascular repair with inflow
typically originating from the iliac arteries. The subsequent endograft repair can be placed at the
same setting or delayed for several days or weeks following the original operation, depending
on the patient's physiologic status. We generally prefer a staged visceral debranching procedure
in advance of thoracic endovascular repair.

Similarly, when subclavian debranching is elected, we typically perform the procedure one to
three days prior to the endovascular repair.

MEDICAL RISK ASSESSMENT

Although endovascular repair of the thoracic aorta is associated with lower perioperative
morbidity and mortality compared with open surgical repair, there is a risk that conversion to an
open repair will be necessary, and thus, patients should be evaluated and prepared as if
undergoing an open surgical repair. Whenever possible, patients should undergo a
comprehensive assessment of medical comorbidities prior to aortic repair including cardiac,
pulmonary, and renal evaluation, also taking into account hypertension and patient age as

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relevant risk factors for morbidity and mortality. The evaluation of cardiopulmonary risk and risk
management strategies are discussed in detail elsewhere. (See "Evaluation of cardiac risk prior
to noncardiac surgery" and "Management of cardiac risk for noncardiac surgery" and "Evaluation
of preoperative pulmonary risk" and "Strategies to reduce postoperative pulmonary
complications in adults".)

PREOPERATIVE PREPARATION

Antibiotic prophylaxis — Antibiotic prophylaxis is recommended within 30 minutes of the skin


incision. Appropriate antibiotics are given in the table (table 2) [98]. Antibiotics are discontinued
within 24 hours given the lack of added benefit beyond that time frame. (See "Antimicrobial
prophylaxis for prevention of surgical site infection in adults", section on 'Vascular surgery'.)

Measures to prevent acute renal injury — The incidence of acute kidney injury following
thoracic aortic endografting is 10 to 15 percent [99-102]. Higher incidences of renal dysfunction
can occur in patients with type B dissection, as these patients are typically treated only after
organ malperfusion has occurred. Important risk factors for postoperative renal dysfunction
include poor preoperative renal function, the need for blood transfusion, and the extent of
thoracoabdominal aortic disease [102]. (See "Surgical and endovascular management of type B
aortic dissection".)

Most patients do not experience acute kidney injury as a result of intravenous contrast. Provided
that there are adequate seal zones, thoracic endovascular repair can be performed with as little
as 60 to 80 mL of contrast. Prevention of contrast-induced nephropathy for those who are at risk
is discussed elsewhere. (See "Prevention of contrast-induced acute kidney injury associated
with angiography".)

Minimizing spinal ischemia — Spinal drainage should be used in cases where there will be
extensive coverage of the thoracic aorta, a history of prior open or endovascular aneurysm repair,
or presence of internal iliac artery occlusions, all of which increase the risk for spinal cord
ischemia (SCI) with the potential for paraplegia [103-108]. In a review of 72 patients, the
incidence of spinal cord ischemia was 12.5 percent for those who had prior abdominal aortic
aneurysm (AAA) repair, compared with 1.7 percent for those without (risk ratio 7.2, 95% CI
2.6-19.6) [103]. A retrospective cohort study of endovascular repair (Crawford Type II
thoracoabdominal aneurysm) using branched stent-grafts suggested staged repair (median
time between stages was five months) reduced the risk for SCI compared with combined
procedures (11.1 versus 37.5 percent) [109]. (See 'Spinal perfusion' above.)

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Spinal drainage decreases pressure in the subarachnoid space, thereby increasing spinal cord
perfusion pressure (spinal cord perfusion pressure = mean arterial pressure - CSF pressure),
and is an important adjunct for reducing spinal ischemia following endovascular repair of the
thoracic aorta [110,111]. Spinal drainage is accomplished by placing a drain at the level of the
L3-L4 disc into the subarachnoid space. (See "Anesthesia for endovascular aortic repair",
section on 'Neuromonitoring for spinal cord ischemia'.)

ENDOGRAFT PLACEMENT

Endovascular repair of the thoracic aorta is typically performed under general endotracheal
anesthesia. Technical success rates are generally high. In one study, technical success was
achieved in 87 percent of patients with aortic aneurysm and 89 percent of patients with aortic
dissection [112].

Vascular access — Performance of the procedure requires the delivery of a large-bore sheath
into the aorta as well as a separate access for arteriography. These are typically accomplished
using femoral cut down. There are no thoracic endovascular devices labelled for percutaneous
use [113]. However, with the growing appeal of percutaneous repair of the abdominal aorta, it is
likely over time that the application of this technique for thoracic endovascular repair will follow
suit [114].

Anticipation of the need for other access techniques, which is required in 9.4 to 23.8 percent of
patients, is important because of the obligatory large sheath size for delivery of the device
[5,10,115]. Passage of the sheath through a small-diameter, tortuous, or excessively calcified
external iliac artery can lead to iliac artery disruption. Adjunctive and alternative access
techniques include balloon angioplasty/stenting of the iliac arteries prior to sheath placement,
creation of an iliac conduit, direct exposure of the common iliac artery, direct delivery through the
abdominal aorta, or use of a controlled rupture technique with a specialized device (eg, Solopath
sheath, Terumo).

Antegrade access to place a descending thoracic endograft can also be obtained using a graft
anastomosed to the ascending aorta [113,116], typically as a means to address the residual
dissection flap after repair of type A aortic dissection.

Graft deployment — Once access is achieved, aortography or other techniques such as


intravascular ultrasound or transesophageal echocardiography [117,118], are used together to
position and deploy the endograft precisely at the target locations [119]. When deploying a graft
near the aortic arch, it is important to provide a projection that adequately splays out the arch

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vessels. A 30- to 60-degree left anterior oblique projection is generally used. For a distal landing
zone near the celiac artery, a lateral projection is required. The instructions for use (IFUs) provide
the precise sequence of steps for individual devices.

Prior to graft deployment, we generally lower the blood pressure keeping the mean blood
pressure in the 60s, which helps prevent the graft from prematurely deploying and moving
distally due to pressure (ie, the "wind-sock effect"). Once the device is deployed, the stent-graft is
typically ballooned at the proximal and distal landing zones, as well as at graft junctions.
Lowering the pressure may also be useful during graft ballooning.

Evaluating for endoleak — Repeat aortography is performed at the conclusion of the procedure
to ensure effective sac exclusion, preservation of essential vessels, and to detect any evidence
of endoleak. An endoleak is the persistent flow in the aneurysm sac following endovascular
repair of the aorta. The classification (table 1) and management of endoleak are discussed in
detail separately. (See "Endoleak following endovascular aortic repair", section on 'Etiology and
classification'.)

Once exclusion of the sac has been confirmed, the device sheath is removed, and the
arteriotomy is repaired or closed with a closure device.

POSTOPERATIVE CARE AND FOLLOW-UP

Postoperatively, the patient is transferred to a monitored setting for routine neurologic and
vascular checks to detect for complications such as stroke, spinal cord ischemia, or extremity
ischemia. (See 'Perioperative morbidity and mortality' below.)

In the absence of complications, recovery is generally rapid and patients require only two to
three days on a regular floor prior to discharge.

Postoperative endograft surveillance — Computed tomographic (CT) angiography is usually


obtained within a month of the procedure, followed by an imaging study at six months and
annually thereafter. Thoracic endovascular aortic repair (TEVAR) in patients with less than ideal
anatomy warrants more rigorous follow-up [120]. Noncontrast CT allows for measurement of the
sac diameter and is sufficient in most circumstances to document effective aneurysm exclusion.
Magnetic resonance angiography is an alternative, although it is of limited applicability in
patients with significant renal dysfunction.

Secondary aortic intervention is relatively common following thoracic endovascular aortic repair
[121,122]. Evidence of attachment site endoleak is intervened upon promptly. Type II endoleaks

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can be observed if the sac does not enlarge. (See 'Late complications and outcomes' below and
"Endoleak following endovascular aortic repair", section on 'Endoleak management after
TEVAR'.)

PERIOPERATIVE MORBIDITY AND MORTALITY

Perioperative mortality with second-generation thoracic stent-grafts placed under elective


circumstances is low, ranging from 1.9 to 3.1 percent [5,6,8]. The operative indication for thoracic
endovascular aortic repair (TEVAR) was not found to be a predictor of poor patient outcome in a
review of the National Surgical Quality Improvement Program (NSQIP) database [123], or in a
later single-institution review [124]. However, patients undergoing thoracic aortic endografting for
emergency reasons, such as due to aortic rupture or aortic dissection, have higher rates of
perioperative (30-day) mortality (23 versus 6.2 percent in NSQIP study) [112,123,125-129]. Late
mortality following emergency repair was significantly worse in one review [130], but in another
review no different among those who survived >30 days [126]. In the NSQIP review, increasing
surgical complexity significantly increased mortality and serious adverse event rates. In a study
that combined perioperative morbid events (myocardial infarction, respiratory events such as
pneumonia or ventilation for more than 24 hours, stroke, and paraplegia), the overall incidence
of perioperative morbidity was 9 percent [5]. The risk of perioperative death is associated with
the degree of chronic renal dysfunction [131-133]. No differences in survival have been identified
for male versus female patients undergoing TEVAR [126,134-139].

Complications specific to graft placement are related to the access site and ischemia related to
thromboembolism during graft placement, the consequences of covering aortic side branches,
or more rarely, retrograde aortic dissection, which can occur during the initial placement or can
be delayed [137-141]. In a systematic review, the pooled incidence of retrograde aortic
dissection was 2.5 percent and was associated with hypertension, history of vascular surgery,
acute (versus chronic) aortic dissection, aortic dissection (versus aneurysm), and use of bare
(versus covered) stents [141].

Aortobronchial or aortopulmonary fistulas, typically related to bronchial compression as a


consequence of endoleak, are rare complications. In one review, these were lethal in 33 and 45
percent of patients, respectively [142].

Iliofemoral access complications are similar to those that occur with endovascular repair of the
abdominal aorta. In one review of iliofemoral complications associated with thoracic
endovascular repair, the complication rate was 12 percent [115]. (See "Complications of

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endovascular abdominal aortic repair", section on 'Access site complications'.)

Ischemic complications

Spinal cord ischemia — The risk of spinal cord ischemia (SCI) has been reported to be
between 3 to 11 percent [105,112,125,132,133,143-149], comparable to the rate of open surgery
[150]. (See "Overview of open surgical repair of the thoracic aorta".)

Some studies have demonstrated lower rates of SCI with TEVAR than with open surgery [8,13].
In a well-performed, retrospective review of 724 patients at a single institution who were treated
with either TEVAR (n = 352) or open surgery (OS; n = 372) for thoracic or thoracoabdominal
aneurysms, no statistically significant difference in the rate of SCI was found between the two
approaches (4.3 versus 7.5 percent, respectively) [13]. In a retrospective review of 424 patients
who underwent TEVAR, of the 12 patients developed spinal cord ischemia, one-half had a prior
open or endovascular aortic repair [148]. The onset of spinal cord ischemia developed at a
mean of 10.6 hours following repair. In this manner, only a portion of the aorta is covered at a
time.

Studies using protocols calling for proactive spinal cord protection report a similar range of rates
of spinal cord ischemia: 1.1 percent in one review and 6 percent in another [105,151]. In a
systematic review, pooled rates for spinal cord ischemia for series reporting routine prophylactic
drain placement or no prophylactic drain placement were 3.2 and 3.5 percent, respectively.

The extent of thoracic aortic coverage is the greatest risk factor for spinal cord ischemia [13,144].
Other studies have identified perioperative hypotension and long procedure duration
[104,105,152], and visceral artery reimplantation as risk factors [144]; another review identified
renal insufficiency as significant [148].

Cerebrovascular ischemia — Because the proximal seal zone is in proximity to the carotid
and vertebral arteries, embolic strokes can occur following TEVAR. Risk factors for embolic
stroke include the need for proximal deployment of the graft, presence of mobile atheromata in
the arch, and prior stroke [153]. Emboli through the vertebral arteries arising from the subclavian
may be the source of posterior circulation strokes [79,83,154]. Perioperative stroke has ranged
from 4 to 8 percent [72,125,155-160], comparable to open surgery [150].

Silent cerebral embolization occurs frequently, but the significance is not known for certain [161].

Extremity ischemia — As described above, planned coverage of the left subclavian artery in
patients at risk should be preceded by carotid-subclavian bypass or transposition. (See 'Arch
vessel bypass' above.)

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Left upper extremity ischemia is infrequent after coverage of the left subclavian artery. Symptoms
can occur to a variable extent but require intervention in a minority of patients [73,162-164]. (See
'Arch vessel bypass' above.)

In a systematic review that included 4906 patients, it was noted that although revascularization
decreased the incidence of later ischemic complications, perioperative mortality and other
complications were increased [78]. In a review of 111 patients undergoing TEVAR without prior
extremity bypass, 13/50 patients in the full-coverage group and 2/25 patients in the partial-
coverage group suffered from vertebrobasilar insufficiency [163]. No paraplegia or stroke was
observed.

Visceral ischemia — Visceral ischemia can occur with coverage of the celiac axis, although
reports have suggested that collateralization through an intact pancreaticoduodenal arcade
allows for extension of the distal seal zone to the level of the superior mesenteric artery (SMA)
without physiologic consequence [53,165]. Similarly, stenting to below the level of the SMA or
renal artery requires revascularization of these vessels, or the use of specialized grafts [95].
(See 'Visceral artery bypass' above and 'Need for debranching procedures' above.)

In a review of 171 patients, independent predictors of acute kidney injury (AKI), which occurred in
24 patients (14 percent), included preoperative depressed estimate glomerular filtration rate,
extent of thoracoabdominal repair, and postoperative transfusion [102]. Survival was significantly
lower for those who experienced AKI.

Postimplantation syndrome — Postimplantation syndrome can occur during the early


postoperative period and is characterized by leukocytosis, fever, and elevation of inflammatory
mediators such as C-reactive protein, IL-6, and TNF-alpha [166-168]. It is thought to be due to
endothelial activation by the endoprosthesis. For thoracic aortic stent-grafts, development of
either unilateral or bilateral reactive pleural effusions is not uncommon, with a reported
incidence of 37 percent to 73 percent [167,169,170].

LATE COMPLICATIONS AND OUTCOMES

Late outcomes for thoracic aortic stent-grafting are primarily related to the natural history of the
disease being treated, as well as the consequences of device complications such as endoleak,
device migration, infolding, or collapse [47].

A retrospective review of the United States Medicare database identified nearly 12,000 patients
who underwent endovascular repair of the thoracic aorta between 2005 and 2010 for a variety of

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indications [129]. Median survival was 57.6 months (95% CI 55 to 61 months). Early and late
mortality depended upon underlying aortic pathology. Patients undergoing thoracic endovascular
aortic repair (TEVAR) for acute dissection or traumatic transection had the highest incidence of
perioperative death but also had the lowest incidence of late mortality, perhaps due to younger
age and smaller number of comorbidities. Isolated aneurysm patients, in particular those not
requiring subclavian artery coverage, had the lowest incidence of perioperative death, although
they had a relatively higher incidence of late death. Aortic rupture was associated with a high
incidence of early and late death. A sobering finding of this large analysis was that among
patients who survived to 180 days, 6 to 12 percent of patients died per year, depending on aortic
diagnosis. The authors of the study questioned whether endovascular repair for patients with
chronic disease, who have an annualized death rate of >10 percent/year, is appropriate.

The incidence of endoleak following thoracic aortic stent placement is lower than for
endovascular repair of the abdominal aorta and is estimated at 3.9 to 15.3 percent [5,6,8,171].
The incidence of endoleak at five-year follow-up with the Gore TAG device was 4.3 percent in one
review. Type I attachment site leaks are the most common type in these and other studies. In a
review of 344 patients undergoing TEVAR, type II endoleaks were more common and occurred
most commonly at the left subclavian artery and intercostal branch sites, followed by visceral
vessels [172]. Among patients who suffered from secondary-endoleak-related rupture, few
(2/10) were related to type II endoleak. Ongoing surveillance for endoleak is necessary [6,173].
(See 'Postoperative endograft surveillance' above and "Endoleak following endovascular aortic
repair", section on 'Endoleak management after TEVAR'.)

Migration of the graft (>10 mm) caudally can occur, with a published incidence of 1 to 2.8 percent
over a 6- to 12-month period [5,6,8]. Factors predisposing to migration include excessive
oversizing and tortuous seal zone anatomy. Device infolding or collapse can also occur, primarily
in young trauma patients, and is related to severe proximal aortic angulation or excessive
oversizing of the device at the time of placement [45,174]. These patients present with
symptoms of acute aortic occlusion [175]. In the case of multiple overlapping stents, device
separation has also been reported [176]. Many of these issues can be managed using
endovascular techniques. (See 'Choice of endograft and endograft sizing' above.)

The rate of secondary intervention required following stent-grafting due to either endoleak or
device migration is 3.6 to 24 percent and depends on the duration of follow-up [5,6,121,177]. In a
review of 585 patients, 12 percent needed reintervention at a median follow-up of 5.6 months
[121]. The need for intervention differed depending upon the indication for initial intervention at
21.3 percent for acute dissection, 16.7 percent for chronic dissection, 10.8 percent for
degenerative aneurysm, 8.1 percent for traumatic transection, and 1.5 percent for penetrating

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ulcer. For degenerative aneurysms, reintervention was needed primarily to treat type I and type III
endoleaks. Repairs that use advanced devices and techniques may have even higher rates of
reintervention [66].

The largest published series, which has reported one-year follow-up, included 443 patients
treated with endovascular stents for a variety of indications, both emergency and elective:
thoracic aortic aneurysm (249 patients), thoracic aortic dissection (131 patients), traumatic aortic
injury (50 patients), and false anastomotic aneurysm (13 patients) [112]. One-year all-cause
mortality among patients treated for aortic aneurysm and aortic dissection were 20 and 10
percent, respectively. These results should not be compared directly to historical outcomes
following surgical repair. Patients included in this series had a greater burden of comorbid
disease, and many would not have been candidates for surgery. The short duration of follow-up
precludes direct comparison with the durable effects of successful surgical repair.

The largest of the early series, for which there is medium-term follow-up, was a prospective,
uncontrolled study of a first-generation, custom-fabricated self-expanding stent-graft, including
103 patients with descending thoracic aortic aneurysms, 60 percent of whom were not
candidates for conventional surgery [160].

After a 1.8-year follow-up, the following findings were noted:

● Fatal complications occurred in 4 percent, including rupture of the treated aneurysm, stent-
graft erosion into the esophagus (aortoesophageal fistula), arterial injury, and excessive
bleeding.

● Late stent-graft complications occurred in 38 percent of patients and included stent-graft


malpositions or removal, endoleak, aortic dissection, distal embolization, gut ischemia, and
infection.

● In a subsequent report at 4.5 years of follow-up, actuarial survival at one, five, and eight
years was 82, 49, and 27 percent, respectively [158]. Patients who had been identified as
suitable surgical candidates at the time of stent-graft placement had significantly better
survival at one year (93 versus 74 percent) and five years (78 versus 31 percent).

In a study of thoracic stenting in the emergency setting, four deaths occurred at a mean follow-up
of 36 months, three of which were attributed to late procedural complications (one aneurysm,
one dissection, and one traumatic transection) [128]. Reintervention rates were similar between
the open surgical and endovascular repair groups.

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SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Aortic and other
peripheral aneurysms".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics."
The Basics patient education pieces are written in plain language, at the 5 th to 6th grade reading
level, and they answer the four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who prefer short, easy-to-
read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and
more detailed. These articles are written at the 10 th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Thoracic aortic aneurysm (The Basics)")

SUMMARY AND RECOMMENDATIONS

● Repair of thoracic aorta may be indicated for various pathologies of the thoracic aorta. For
patients with or without involvement of the abdominal aorta, endovascular stent-grafting has
gained acceptance as a reasonable alternative to open surgery. Despite the significant rate
of secondary intervention required following stent-grafting, the decreased perioperative
morbidity of this approach makes it preferable to open repair for many indications. (See
'Indications for endovascular aortic repair' above.)

● The preprocedural evaluation of patients undergoing thoracic endovascular repair requires


medical risk assessment and a careful quantitative and qualitative evaluation of aortic arch
and aortoiliac anatomy to determine suitability for endovascular repair. (See 'Medical risk
assessment' above and 'Planning TEVAR' above.)

● Available thoracic endovascular grafts have three components (delivery system, main body,

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and extensions). The endovascular graft is constructed by the sequential delivery and
deployment of device components in vivo. Although variations exist from device to device,
there are no clear advantages of one device over another. All approved endografts have
demonstrated short- and mid-term success in treatment of thoracic aortic aneurysms. (See
'Thoracic endografts' above and "Endovascular devices for thoracic aortic repair".)

● Routine follow-up imaging is mandatory following thoracic endovascular stent-grafting to


evaluate endograft integrity and positioning. We use computed tomography to assess the
graft at initial postoperative follow-up, then 6 and 12 months postoperatively, and annually
thereafter. (See 'Postoperative endograft surveillance' above.)

● Perioperative mortality with second-generation thoracic stent-grafts placed under elective


circumstances is low (<3 percent). Perioperative mortality in patients undergoing thoracic
aortic endografting for emergency reasons, such as due to aortic rupture or aortic
dissection, is higher. Perioperative complications specific to graft placement are related to
the access site used to introduce the device, ischemia related to thromboembolism during
graft placement, or as a consequence of covering aortic side branches. The risk of spinal
cord ischemia is comparable to open surgery with rates between 3 and 11 percent. (See
'Perioperative morbidity and mortality' above.)

● Secondary reintervention is not uncommon following thoracic endografting and is related to


endoleak, graft migration, and progression of the underlying disease that indicated the
endograft. Continued surveillance is essential to prevent late aortic events. (See 'Late
complications and outcomes' above.)

ACKNOWLEDGMENT

We are saddened by the death of Emile R Mohler, III, MD, who passed away in October 2017.
UpToDate wishes to acknowledge Dr. Mohler's work as our Section Editor for Vascular Medicine.

Use of UpToDate is subject to the Subscription and License Agreement.

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171. Preventza O, Wheatley GH 3rd, Ramaiah VG, et al. Management of endoleaks associated
with endovascular treatment of descending thoracic aortic diseases. J Vasc Surg 2008;
48:69.

172. Bischoff MS, Geisbüsch P, Kotelis D, et al. Clinical significance of type II endoleaks after
thoracic endovascular aortic repair. J Vasc Surg 2013; 58:643.

173. Ganapathi AM, Andersen ND, Hanna JM, et al. Comparison of attachment site endoleak
rates in Dacron versus native aorta landing zones after thoracic endovascular aortic repair.
J Vasc Surg 2014; 59:921.

174. Tadros RO, Lipsitz EC, Chaer RA, et al. A multicenter experience of the management of
collapsed thoracic endografts. J Vasc Surg 2011; 53:1217.

175. Shukla AJ, Jeyabalan G, Cho JS. Late collapse of a thoracic endoprosthesis. J Vasc Surg
2011; 53:798.

176. Perek B, Juszkat R, Kulesza J, Jemielity M. Stent grafts separation 6 years after
endovascular repair of a thoracic aortic aneurysm. J Vasc Interv Radiol 2014; 25:1650.

177. Szeto WY, Desai ND, Moeller P, et al. Reintervention for endograft failures after thoracic
endovascular aortic repair. J Thorac Cardiovasc Surg 2013; 145:S165.

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GRAPHICS

Safi modification of Crawford TAAA classification

T he C rawford c las s ific ation of TA A A is bas ed upon the ex tent of aortic


inv olv ement.
Ty pe I aris es from abov e the s ix th interc os tal s pac e, us ually near the left
s ubc lav ian artery, and ex tends to inc lude the origins of the c eliac ax is and
s uperior mes enteric arteries . A lthough the renal arteries c an als o be
inv olv ed, the aneury s m does not ex tend into the infrarenal aortic s egment.
Ty pe I I aneury s m als o aris es abov e the s ix th interc os tal s pac e and may
inc lude the as c ending aorta, but ex tends dis tal to inc lude the infrarenal
aortic s egment, often to the lev el of the aortic bifurc ation.
Ty pe I I I aneury s m aris es in the dis tal half of the des c ending thorac ic aorta,
below the s ix th interc os tal s pac e, and ex tends into the abdominal aorta.
Ty pe I V aneury s m generally inv olv es the entire abdominal aorta from the
lev el of the diaphragm to the aortic bifurc ation.
Ty pe V aneury s m aris es in the dis tal half of the des c ending thorac ic aorta,
below the s ix th interc os tal s pac e, and ex tends into the abdominal aorta, but
is limited to the v is c eral s egment.

TAAA: thoracoabdominal aortic aneurysm.

Adapted from: Safi HJ, Winnerkvist A, Miller CC 3rd, et al. Effect of extended cross-clamp time
during thoracoabdominal aortic aneurysm repair. Ann Thorac Surg 1998; 66:1204.

Graphic 66037 Version 9.0

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Variations of aortic arch branching

V ariations in the origin of the aortic arc h branc hes . (A ) and (B ) repres ent the majority of
anomalies found in the general population.
(A ) C ommon origin of the left c ommon c arotid artery and brac hioc ephalic artery (bov ine
arc h). R epres ents 7 3 perc ent of all branc h v ariations .
(B ) O rigin of the left c ommon c arotid from the mid- to upper brac hioc ephalic artery.
R epres ents 2 2 perc ent of all branc h v ariations .
(C ) C ommon c arotid trunk giv ing origin to the left s ubc lav ian artery.
(D ) C ommon c arotid trunk , independent from both s ubc lav ian arteries .
(E ) L eft and right brac hioc ephalic arteries .
(F ) S ingle arc h v es s el (brac hioc ephalic artery ) originates the left c ommon c arotid and left
s ubc lav ian arteries .

Reproduced with permission from: Uflacker R. Atlas Of Vascular Anatomy: An Angiographic Approach, Second
Edition. Philadelphia: Lippincott Williams & Wilkins, 2007. Copyright © 2007 Lippincott Williams & Wilkins.

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Normal thoracic aorta

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Normal abdominal aorta

T he abdominal aorta is a retroperitoneal s truc ture that begins at the


hiatus of the diaphragm and ex tends to its bifurc ation into the right
and left c ommon iliac arteries at the lev el of the fourth lumbar
v ertebra.
T he branc hes of the abdominal aorta inc lude (s uperior to inferior) the
left and right inferior phrenic arteries , the c eliac ax is , left and right
middle s uprarenal arteries , s uperior mes enteric artery, left and right
renal arteries , left and right gonadal arteries , inferior mes enteric
artery, left and right c ommon iliac artery, and middle s ac ral artery. T he
paired lumbar arteries (L 1 - L 4 ) branc h from the aorta at mid v ertebral
body.

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Pelvic circulation

Illustration modified with permission from: Uflacker R. Atlas Of Vascular Anatomy: An Angiographic
Approach, Second Edition. Philadelphia: Lippincott Williams & Wilkins. Copyright © 2006 Lippincott
Williams & Wilkins.

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Aortic stent zones of attachment

T he figure depic ts the pos s ible prox imal landing zones for a thorac ic aortic
s tent- graft. the prox imal edge of the c ov ered endograft is :

Z one 0 : prox imal to the innominate artery origin


Z one 1 : dis tal to the innominate but prox imal to the left c ommon c arotid
artery origin
Z one 2 : dis tal to the left c ommon c arotid artery but prox imal to the
s ubc lav ian artery
Z one 3 : ≥2 c m of the left s ubc lav ian artery without c ov ering it
Z one 4 : 2 c m dis tal to the left s ubc lav ian artery and ends within the prox imal
half of the des c ending thorac ic aorta (T 6 approx imating the midpoint of the
des c ending thorac ic aorta)
Z one 5 : s tarts in the dis tal half of the des c ending thorac ic aorta but prox imal
to the c eliac artery
Z one 6 : c eliac origin to the top of the s uperior mes enteric artery
Z one 7 : S M A origin, s uprarenal aorta

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SMA: supe rior m e se nte ric arte ry.


Fillinger MG, Greenberg RK, McKinsey JF, et al. Reporting standards for thoracic endovascular
aortic repair (TEVAR). J Vasc Surg 2010; 52:1022.

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Arterial supply of the spinal cord

Reproduced with permission from: Prasad S, Price RS, Kranick SM, et al. Clinical
Reasoning: A 59-year-old woman with acute paraplegia. Neurology 2007; 69:E41.
Copyright © 2007 Lippincott Williams & Wilkins.

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Types of endoleak

Type of endoleak Definition

Type I

Ia Inadequate seal at proximal end of endograft

Ib Inadequate seal at distal end of endograft

Ic Inadequate seal at iliac occluder plug

Type II Backflow of blood from aortic collaterals into the aneurysm sac

Type III Flow from visceral vessel (lumbar, IMA, accessory, renal hypogastric) without
attachment site connection

IIIa: component disconnection Flow from module disconnection

IIIb: stent fabric disturbance Flow from fabric disruption (minor: <2 mm; major: ≥2 mm)

Type IV Flow from porous fabric (<30 days after graft placement)

Endoleak of undefined origin Flow visualized but source unidentified


(Type V)

IMA: inferior mesenteric artery.

Reproduced from: Chaikof EL, Blankensteijn JD, Harris PL, et al. Reporting standards for endovascular aortic aneurysm
repair. J Vasc Surg 2002; 35:1048. Table used with the permission of Elsevier Inc. All rights reserved.

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Antimicrobial prophylaxis for percutaneous procedures in adults

Potential Routine First- Common


Procedure organisms prophylaxis choice antibiotic Comments
encountered recommended antibiotic choices

Angiography, Staphylococcus No None Cefazolin (2 g IV if Procedure


angioplasty, aureus, S. <120 kg, 3 g IV if classification:
thrombolysis, epidermidis ≥120 kg IV) (if high- clean
arterial closure risk stent infection).
device If penicillin-allergic,
placement, can use vancomycin
stent (15 mg/kg IV; max
placement 2 g) or clindamycin
(900 mg IV).

Endograft S. aureus, S. Yes Cefazolin (2 If penicillin-allergic, Procedure


placement epidermidis g IV if <120 can use vancomycin classification:
kg, 3 g IV if or clindamycin clean
≥120 kg IV)

Superficial S. aureus, S. No None None Procedure


venous epidermidis classification:
insufficiency clean
treatment

IVC filter S. aureus, S. No None None Procedure


placement epidermidis classification:
clean

Tunneled S. aureus, S. No consensus None Cefazolin (2 g IV if Procedure


central venous epidermidis <120 kg, 3 g IV if classification:
access ≥120 kg IV) (eg, clean
immunocompromised (nontunneled
patients before catheter: no
chemotherapy; prophylaxis)
history of catheter
infection). If
penicillin-allergic, can
use vancomycin (15
mg/kg IV; max 2 g)
or clindamycin (900
mg IV).

I V : intrav enous ; I V C : inferior v ena c av a.

Reproduced from: Venkatesan AM, Kundu S, Sacks D, et al. Practice guideline for adult antibiotic prophylaxis during
vascular and interventional radiology procedures. J Vasc Interv Radiol 2010; 21:1611. Table used with the permission of
Elsevier Inc. All rights reserved.

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Contributor Disclosures
Grace J Wang, MD Nothing to disclose Ronald M Fairm an, MD Nothing to disclose Gabriel S Aldea,
MD Nothing to disclose John F Eidt, MD Nothing to disclose Joseph L Mills, Sr, MD Grant/Research
/Clinical Trial Support: Voyager Trial [Peripheral artery disease (Rivoxaraban)]. Consultant/Advisory Boards:
Innomed [Peripheral artery disease (Femoral artery stent)]. Equity Ow nership/Stock Options: NangioTx
[Peripheral artery disease (Self-assembling nanotubules)]. Other Financial Interest: Elsevier; Rutherford
[Vascular surgery (Rutherford and Comprehensive Vascular and Endovascular Surgery
textbooks)]. Kathryn A Collins, MD, PhD, FACS Nothing to disclose

Contributor disclosures are review ed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.

Conflict of interest policy

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