Emergency procedures on the descending thoracic aorta in the endovascular era

• Published in: Journal of vascular surgery 2011-11, Vol.54 (5), p.1298-1302
• Main Authors: Mitchell, Marc E., MD, Rushton, Fred W., MD, Boland, A. Bradley, MD, Byrd, Taylor C., BS, Baldwin, Zachary K., MD
• Format: Article
• Language: English
• Subjects: Academic Medical Centers; Adolescent; Adult; Aged; Aged, 80 and over; Aneurysm, Dissecting - surgery; Aorta, Thoracic - injuries; Aorta, Thoracic - surgery; Aortic Aneurysm, Thoracic - surgery; Aortic Diseases - mortality; Aortic Diseases - surgery; Aortic Rupture - surgery; Biological and medical sciences; Blood and lymphatic vessels; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation - adverse effects; Blood Vessel Prosthesis Implantation - instrumentation; Blood Vessel Prosthesis Implantation - mortality; Cardiology. Vascular system; Diseases of the aorta; Emergencies; Endovascular Procedures - adverse effects; Endovascular Procedures - instrumentation; Endovascular Procedures - mortality; Female; Humans; Male; Medical sciences; Middle Aged; Mississippi; Patient Selection; Postoperative Complications - etiology; Postoperative Complications - mortality; Postoperative Complications - surgery; Prosthesis Design; Reoperation; Retrospective Studies; Stents; Surgery; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Time Factors; Treatment Outcome; Vascular surgery: aorta, extremities, vena cava. Surgery of the lymphatic vessels; Vascular System Injuries - mortality; Vascular System Injuries - surgery; Young Adult
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2011.05.010

Background Thoracic endovascular aortic repair (TEVAR), initially developed for the treatment of degenerative aneurysms of the descending thoracic aorta, has been applied to the entire spectrum of descending thoracic aortic pathology in both the elective and emergent settings. This single center study evaluates the effectiveness of TEVAR for the treatment of acute surgical emergencies involving the descending thoracic aorta, including traumatic aortic disruption (TAD), ruptured descending thoracic aneurysm (RDTA), and acute complicated Type B dissection (cTBD). Methods A retrospective review of the medical records of all patients undergoing emergent TEVAR at the University of Mississippi Medical Center between August 2007 and November 2010 was undertaken. Patients were studied for 30-day survival, complications, type of device used for the repair, and technical aspects of the procedure. Results A total of 44 patients (59% male) with an average age of 49 years (range, 16-87 years) underwent emergent TEVAR during the study period. The technical success rate was 100%, with no patient requiring emergent open surgery for conditions involving the descending thoracic aorta at our institution during the study period. The majority (73%) of the repairs were accomplished using commercially available thoracic stent grafts. Abdominal endograft proximal extension cuffs were used in 12 (38%) of the 32 patients undergoing repair of TAD. Twenty-one patients (48%) required coverage of the left subclavian artery, two (10%) of whom subsequently required subclavian artery revascularization. Procedure-related complications included two strokes, one spinal cord ischemia, one unintentional coverage of the left carotid artery, one episode of acute renal failure, and three access site injuries. One patient undergoing repair of TAD had collapse of the stent graft in the early postoperative period. He was successfully treated by placement of an additional stent graft. Seven patients (16%) died within 30 days of surgery. Three of the deaths occurred in patients who had successfully undergone repair of a TAD and died of associated injuries. Conclusions Emergent TEVAR has become the treatment of choice for acute surgical emergencies involving the descending thoracic aorta. Short-term morbidity and mortality compare favorably with historic results for emergent open surgical procedures on the descending thoracic aorta. Survival is highest in patients undergoing repair of TAD. Using curren