Endovascular Therapy for the Thoracic Aorta

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Citation
US Cardiology, 2007;4(2):55-6

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The introduction of endovascular stent graft technology has ushered in a new era in therapy for diseases of the descending thoracic aorta. This ‘radical and revolutionary’ stent graft technology has been accompanied by simultaneous advances in non-invasive imaging and materials technology. The technical challenges of stent graft deployment in the descending thoracic aorta—such as proximity to the great vessels and arch tortuosity— have been and remain a device engineering focus. The promise of these new tools is the long-term repair of thoracic aortic disease processes such as aneurysm or dissection with minimal associated morbidity and mortality.
However, it must be remembered that the pathophysiology of vascular disease is fundamental. The lessons learned from decades of open surgical management of thoracic aortic disease are applicable to the implementation of this endovascular technology. Therefore, we believe clinicians should not deviate from the established indications for operative intervention. In addition, the anatomical limitations of various stent devices should be respected. One should not hesitate to proceed with open repair in the face of unfavorable endovascular anatomy and a surgical indication.
The proper implementation of stent graft technology is dependent on high-quality imaging in the pre-, intra-, and post-operative periods. Specifically, multidetector computed tomography (MDCT) with 3D reconstructions has made device selection and stent deployment strategy (i.e. access route for large sheaths) more exact and safer. The authors generally prefer computed tomography angiography (CTA) to magnetic resonance imaging (MRI) unless confronted with renal insufficiency. Also, intravascular ultrasound is a useful tool when attempting to minimize contrast use and in the analysis of aortic wall pathology, e.g. in acute and chronic aortic dissection. In addition, the introduction of improved non-invasive imaging has brought disease processes to the attention of physicians that previously were encountered relatively rarely, i.e. intramural hematoma and penetrating aortic ulcer. The natural history and management of these entities is not well defined in the literature, and represent another area for investigation and broadening the scope of thoracic aortic intervention.

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References
  1. Cheung AT PA, McGarvey ML, Appoo JJ, et al., Ann Thorac Surg, 2005; 80:1280–88.
    Crossref | PubMed
  2. Weigang EHM, Siegenthaler MP, Beckmann NA, et al., Ann Thorac Surg, 2006;82(5):1679–87.
    Crossref | PubMed
  3. Gutsche J, Cheung A, McGarvey M, et al., Ann Thorac Surg, 2007;84(4):1195–1200, discussion 1200.
    Crossref | PubMed
  4. Clouse W, Hallett J, Schaff H, et al., JAMA, 1998;280(22): 1926–9.
    Crossref | PubMed
  5. Coady M, Rizzo J, Goldstein L, Elefteriades J, Cardiol Clin, 1999;(17):615–35.
    Crossref | PubMed
  6. Johansson G, Markstrom U, Sweedenborg J, J Vasc Surg, 1995;21:985–8.
    Crossref | PubMed
  7. Stone D, Brewster D, Kwolek C, et al., J Vasc Surg, 2006;44:1188–97.
    Crossref | PubMed
  8. Hamerlijnck R, Rutsaert R, De Geest R, et al., J Vasc Surg, 1989;9:568–73.
    Crossref | PubMed
  9. Makaroun M, Dillavou E, Kee S, et al., J Vasc Surg, 2005;41: 1–9.
    Crossref | PubMed
  10. Bavaria J, Appoo J, Makaroun M, et al., J Thorac Cardiovasc Surg, 2007;133:369–77.
    Crossref | PubMed
  11. Appoo JJ, Moser WG, Fairman RM, et al.,J Thorac Cardiovasc Surg, 2006;131(5):1087–94.
    Crossref | PubMed
  12. Tehrani HY, Peterson BG, Katariya K, et al., Ann Thorac Surg, 2006;82(3):873–7; discussion 877–78.
    Crossref | PubMed
  13. Wheatley GH III, Gurbuz AT, Rodriguez-Lopez JA, et al., Ann Thorac Surg, 2006;81(5):1570–77.
    Crossref | PubMed
  14. Parmer S, Carpenter J, Stavropoulos W, et al., J Vasc Surg, 2006;44:447–52.
    Crossref | PubMed
  15. Gottardi R, Lammer J, Grimm M, et al., Eur J Cardiothorac Surg, 2006;29(2): 258–60.
    Crossref | PubMed
  16. Greenberg R, Haddad F, Svensson L, et al., Circulation, 2005;112:2619–26.
    Crossref | PubMed
  17. Crawford E, Hess K, Cohen E, et al., Ann Surg, 1991;213:417–25.
    Crossref | PubMed
  18. Kaya A, Heijmen RH, Overtoom TT, et al., Ann Thorac Surg, 2006;82(2):560–65.
    Crossref | PubMed
  19. Hagan PG, Nienaber CA, Isselbacher EM, et al., JAMA, 2000;283(7):897–903.
    Crossref | PubMed
  20. Estrera A, Miller C, Goodrick J, et al., Ann Thorac Surg, 2007;83: S842–5.
    Crossref | PubMed
  21. Eggebrecht H, Nienaber C, Neuhauser M, et al., Eur Heart J, 2006;27:489–98.
    Crossref | PubMed
  22. Leurs LJ, Bell R, Degrieck Y, Thomas S, et al.,J Vasc Surg, 2004;40(4):670–80.
    Crossref | PubMed