Endovascular management of thoracic aortic aneurysm
Indications and technique. Because of the considerable morbidity and mortality associated with surgical repair of descending thoracic aneurysms, the endovascular approach to aneurysm exclusion is particularly attractive. The decision to proceed with endovascular graft placement is based on similar anatomic considerations as for AAA: adequate length (2 cm) and diameter (20 to 37 mm) of the proximal and distal aneurysm necks, absence of significant mural thrombus within the neck, and aortic and iliofemoral anatomy amenable to device introduction. In situations in which the proximal neck length is too short, seating of the proximal graft end over the origin of the left subclavian artery has been performed successfully with or without an adjunctive left carotid-left subclavian transposition or bypass. Only one device, the TAG graft (W. L. Gore and Associates, Flagstaff, Arizona), is approved in the United States for the treatment of Thoracic Aortic Aneurysm at this time, with other devices on the horizon.
Results and complications. Early results for the use of endovascular devices are encouraging. Various studies have suggested low morbidity and mortality and high rates of aneurysm exclusion (J Vasc Interv Radiol 2004;15:361, J Vasc Surg 2005;42:1063, Ann Thorac Surg 2006;81:1570). Future fenestrated and branched devices may allow endovascular treatment of more complex arch and thoracoabdominal aneurysms, but this technology is in the developmental phase