II. ENDOVASCULAR PROCEDURES. SHORT AND LONG-TERMS RESULTS  THE MULTIFOCAL ATHEROSCLEROTIC PATIENT
DIAGNOSIS AND MANAGEMENT IN 2003 

The Journal of Cardiovascular Surgery 2003 June;44(3):349-61

Copyright © 2009 EDIZIONI MINERVA MEDICA

language: English

Endovascular treatment of thoracic aortic aneurysms

Bergeron P., De Chaumaray T., Gay J., Douillez V.

Department of Thoracic and Cardiovascular Surgery Saint Joseph Hospital, Marseille, France

Descending tho­racic ­aortic aneu­rysms (TAA) and ­chronic dis­sec­tions ­have ­high mor­bidity and mor­tality ­rates. For 10 ­years, the evo­lu­tion of ­both ­imaging tech­niques and ­aortic ­stent-­graft ­design has ­brought a new ther­a­peutic ­hope for ­patients at ­high ­risk for sur­gery pre­senting non-rup­tured or emer­gency ­cases of TAA. Our ­goal is to ­describe the endo­vas­cular tech­nique, ­review its ­state of the art and com­pare its mid-­term ­results to ­those of con­ven­tional sur­gery. We ­also ­describe sur­gical ­ways to ­manage com­plex TAA, ­involving the ­aortic ­arch and/or the ­celiac ­aorta, as ther­a­peutic solu­tions for ­high ­risk ­patients for sur­gery ­with ­unfitted ­anatomy for endo­vas­cular ­repair. ­After a ­review of the lit­er­a­ture ­dealing ­with the nat­ural his­tory, the eti­ology, and the sur­gical treat­ment, we ­describe the endo­vas­cular ­devices, the con­ven­tional ­stent-­grafting tech­nique and we ­detail the adjunc­tive pro­ce­dures we ­used to ­manage com­plex ­cases. We ­then ret­ro­spec­tively ­report our per­sonal 38-­patient expe­ri­ence ­from ­October 1999 to Feb­ruary 2003. ­Thirty-­three ­patients pre­sented ­with TAA and the ­average age was 70 ­years old (35-88), ­while the ­male/­female ­ratio was 5.3. All of ­them ­were at ­high ­risk for sur­gery, of ­which 27% ­required adjunc­tive pro­ce­dures to ­achieve prox­imal and/or ­distal ­neck man­age­ment. The in-hos­pital ­death ­rate was 9%. We ­reported no ­case of par­a­plegia and ­only 1 ­patient ­with ­post-oper­a­tive regres­sive ­stroke (3%). All the aneu­rysmal ­sacs ­were suc­cess­fully ­excluded ­without ­early endo­leak. ­During ­follow-up ­period (­mean: 2 ­years; 1-40 ­months), we ­observed a ­late ­death ­rate of 10%. All aneu­rysmal sac ­remained ­excluded by the endo­grafts and no ­stent-­graft migra­tion was ­observed. No ­late endo­leak ­appeared ­during the ­follow-up ­course, but 1 ­patient pre­sented a prox­imal ­aortic enlarge­ment, ­which ­required ­total trans­po­si­tion of the ­supra-­aortic ves­sels and ­stent-­graft exten­sion. The endo­vas­cular ­repair of TAA and ­chronic dis­sec­tions ­proved to be fea­sible and ­offers ­hopeful mid-­term ­results. ­With a ­very low mor­bidity-mor­tality ­rate, com­pared to sur­gery, the endo­vas­cular tech­nique may rep­re­sent an unques­tion­able ther­a­peutic ­options, espe­cially for ­patients at ­high ­risk for sur­gery. How­ever, ­long-­term ­results are ­needed to ­point out the dur­ability of ­descending tho­racic ­aortic ­stent-­grafting. ­Neck man­age­ment ­must be encour­aged in ­order to ­avoid ­type 1 endo­leaks in ­cases ­with ­short ­landing ­zones.