Current status of endovascular treatment for thoracoabdominal aortic aneurysms
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REVIEW ARTICLE
Current status of endovascular treatment for thoracoabdominal aortic aneurysms Takeshi Baba1 · Takao Ohki1 · Koji Maeda1 Received: 26 April 2019 / Accepted: 10 October 2019 © Springer Nature Singapore Pte Ltd. 2019
Abstract Open surgical repair (OSR) for thoracoabdominal aortic aneurysms (TAAAs) is maximally invasive and associated with high rates of operative mortality and perioperative complications including spinal cord ischemia (SCI), despite improvements in surgical techniques and perioperative care. Elderly patients, patients with a history of aortic surgery, and patients with severe comorbidities are often considered ineligible for this surgery and endovascular treatment may be their only treatment option. Total endovascular aneurysm repair (t-EVAR) without debranching surgery does not require thoracotomy and laparotomy and could improve the outcomes of these patients. t-EVAR includes fenestrated EVAR (f-EVAR), multi-branched EVAR (b-EVAR), and physician-modified fenestration endograft (PMFG). Although these techniques have achieved lower mortality rates than OSR, there are concerns about perioperative complications including limb ischemia, SCI, and long-term outcomes such as endograft migration and endoleaks (ELs). This article provides an overview of available endovascular devices for TAAAs and reviews the short and mid-term results of t-EVAR, as well as alternative options. Keywords Thoracoabdominal aortic aneurysms · Fenestrated EVAR · Branched EVAR · Spinal cord ischemia · Endoleak
Introduction Open surgical repair (OSR) is the gold standard of treatment for thoracoabdominal aortic aneurysms (TAAAs). However, despite improvements in surgical techniques, spinal cord protection, and peri-operative critical care support, mortality and perioperative complication rates remain high [1]. In particular, spinal cord ischemia (SCI) is a serious complication that remains unresolved. Other complications include organ ischemia, renal failure, pulmonary hemorrhage, and pneumonia. In fact, several reports have indicated that the 30-day mortality rate of OSR is approximately 5–19% [1, 2]. According to the Japanese Association for Thoracic Surgery and the Japanese Society for Vascular Surgery, the 30-day mortality rate of OSR is 6–10%. In addition to the high mortality rates, the incidence of SCI in patients with Crawford type II TAAA ranges from 2 to 27%, with an average of 10% [3]. Patients with a history of aortic surgery * Takeshi Baba [email protected] 1
Division of Vascular Surgery, Department of Surgery, Jikei University School of Medicine, 3‑25‑8 Nishi‑shinbashi, Minato‑ku, Tokyo 105‑8461, Japan
and those with severe comorbidities, such as cardiac disease and chronic obstructive pulmonary disease (COPD), are at increased surgical risk [4, 5]. Because of its highly invasive nature, many high-risk patients are deemed ineligible for OSR. Thus, fenestrated EVAR (f-EVAR; Cook Medical Inc., Bloomington, IN, USA; Fig. 1), multi-branched EVAR (b-EVAR) (t-Branch; Cook Medical Inc.; Fig. 2), and phys
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