Ulcer/hematoma weakens aortic wall; may progress to dissection or form pseudoaneurysm
Rupture risk with large ulcer/pseudoaneurysm
Intramural hematoma: Hemorrhage within aortic wall without initial intimal disruption
May occur as 1° event in hypertensive patients
May result from penetrating atherosclerotic ulcer
Intramural hematoma weakens aortic wall; may progress to dissection; increased rupture risk
Traumatic aortic injury: Penetrating or blunt trauma causing various lesions; aortic isthmus is most common site of injury; classified by lesion
Grade 1: Intimal tear
Grade 2: Intramural hematoma
Grade 3: Pseudoaneurysm
Grade 4: Rupture
Pertinent Vascular Anatomy
Thoracic aortic arch divided into zones based on great vessel origins; described as Ishimaru zones 0-4
Brachiocephalic (innominate) artery: 1st branch of thoracic aorta; originates in Ishimaru zone 0
Divides into right common carotid and right subclavian arteries; latter yields vertebral artery
Left common carotid artery: 2nd branch of thoracic aorta; originates in Ishimaru zone 1
Divides into external and internal carotid arteries
Left subclavian artery (LSA): 3rd branch of thoracic aorta; originates in Ishimaru zone 2
Yields left vertebral artery
Thoracic aortic arch distal to LSA is Ishimaru zone 3
Descending thoracic aorta beyond arch curvature is Ishimaru zone 4
Further subdivided into 9 subsegments based on thoracic vertebral segments T4-T12
PREPROCEDURE
Indications
Contraindications
Preprocedure Imaging
Getting Started
PROCEDURE
Patient Position/Location
Procedure Steps
Alternative Procedures/Therapies
POST PROCEDURE
Things to Do
Postprocedure Imaging
OUTCOMES
Problems
Complications
Expected Outcomes
Selected References
Loskutov A et al: Endovascular management of chronic type B aortic dissection. Tech Vasc Interv Radiol. 24(2):100752, 2021
Ogawa Y et al: Improved midterm outcomes after endovascular repair of nontraumatic descending thoracic aortic rupture compared with open surgery. J Thorac Cardiovasc Surg. 161(6):2004-12, 2021
Qrareya M et al: Management of postoperative complications following endovascular aortic aneurysm repair. Surg Clin North Am. 101(5):785-98, 2021
Chen SW et al: Complications and management of the thoracic endovascular aortic repair. Aorta (Stamford). 8(3):49-58, 2020
Hundersmarck D et al: Blunt thoracic aortic injury and TEVAR: long-term outcomes and health-related quality of life. Eur J Trauma Emerg Surg. 2020
Qato K et al: Outcomes of thoracic endovascular aneurysm repair (TEVAR) in patients with connective tissue disorders. Vasc Endovascular Surg. 54(8):676-80, 2020
Teraa M et al: Important issues regarding planning and sizing for emergent TEVAR. J Cardiovasc Surg (Torino). 61(6):708-12, 2020
Youssef A et al: Management of the left subclavian artery during TEVAR - complications and mid-term follow-up. Vasa. 47(5):387-92, 2018
Matsuda H: Treatment of uncomplicated type B aortic dissection. Gen Thorac Cardiovasc Surg. 65(2):74-9, 2017
Sweet M et al: A review of new thoracic devices. endovascular today. Reviewed March 8, 2017. Accessed March 8, 2017. http://evtoday.com/pdfs/et1115_F1_Starnes.pdf
von Allmen RS et al: Editor's choice - incidence of stroke following thoracic endovascular aortic repair for descending aortic aneurysm: a systematic review of the literature with meta-analysis. Eur J Vasc Endovasc Surg. 53(2):176-84, 2017
Abraha I et al: Thoracic stent graft versus surgery for thoracic aneurysm. Cochrane Database Syst Rev. CD006796, 2016
Hongku K et al: Total aortic endovascular repair. J Cardiovasc Surg (Torino). 57(6):784-805, 2016
Chung J et al: Left subclavian artery coverage during thoracic endovascular aortic repair and risk of perioperative stroke or death. J Vasc Surg. 54(4):979-84, 2011
Ullery BW et al: Risk factors, outcomes, and clinical manifestations of spinal cord ischemia following thoracic endovascular aortic repair. J Vasc Surg. 54(3):677-84, 2011
Ueda T et al: Incomplete endograft apposition to the aortic arch: bird-beak configuration increases risk of endoleak formation after thoracic endovascular aortic repair. Radiology. 255(2):645-52, 2010
Lee WA: Failure modes of thoracic endografts: prevention and management. J Vasc Surg. 49(3):792-9, 2009
Matsumura JS et al: The Society for Vascular Surgery Practice Guidelines: management of the left subclavian artery with thoracic endovascular aortic repair. J Vasc Surg. 50(5):1155-8, 2009
Greenberg RK et al: Endovascular repair of thoracic aortic lesions with the Zenith TX1 and TX2 thoracic grafts: intermediate-term results. J Vasc Surg. 41(4):589-96, 2005
Leurs LJ et al: Endovascular treatment of thoracic aortic diseases: combined experience from the EUROSTAR and United Kingdom Thoracic Endograft registries. J Vasc Surg. 40(4):670-9; discussion 679-80, 2004
Related Anatomy
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Related Differential Diagnoses
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References
Tables
Tables
KEY FACTS
Terminology
Preprocedure
Procedure
Outcomes
TERMINOLOGY
Definitions
Thoracic endovascular aortic repair (TEVAR): Endoluminal placement of fabric-covered stent (endograft/stent-graft) to treat thoracic aortic aneurysm (TAA)/other pathology
Endograft extends proximal and distal to aneurysm
Aneurysm sac excluded from pressurized arterial blood flowing through endograft
Dilated/weakened aorta not exposed to flow
Aneurysm sac thromboses; rupture risk negated
TAA: Aortic dilatation exceeding normal diameter by > 50%
Considered aneurysm if transverse diameter > 4 cm
Increased rupture risk if TAA > 5-cm diameter
Rupture risk doubles per 1-cm increment
Various etiologies
Degenerative: Commonly due to atherosclerosis
Abnormal matrix metalloproteinase activity
Etiology in 75% of TAAs
Connective tissue disorders: Genetic conditions associated with acute aortic syndromes/aneurysms
Ehlers-Danlos syndrome: Type IV vascular subgroup characterized by generalized vascular fragility and frequent arterial ruptures
Loeys-Dietz syndrome: Phenotypically similar to Ehlers-Danlos type IV subgroup
Ulcer/hematoma weakens aortic wall; may progress to dissection or form pseudoaneurysm
Rupture risk with large ulcer/pseudoaneurysm
Intramural hematoma: Hemorrhage within aortic wall without initial intimal disruption
May occur as 1° event in hypertensive patients
May result from penetrating atherosclerotic ulcer
Intramural hematoma weakens aortic wall; may progress to dissection; increased rupture risk
Traumatic aortic injury: Penetrating or blunt trauma causing various lesions; aortic isthmus is most common site of injury; classified by lesion
Grade 1: Intimal tear
Grade 2: Intramural hematoma
Grade 3: Pseudoaneurysm
Grade 4: Rupture
Pertinent Vascular Anatomy
Thoracic aortic arch divided into zones based on great vessel origins; described as Ishimaru zones 0-4
Brachiocephalic (innominate) artery: 1st branch of thoracic aorta; originates in Ishimaru zone 0
Divides into right common carotid and right subclavian arteries; latter yields vertebral artery
Left common carotid artery: 2nd branch of thoracic aorta; originates in Ishimaru zone 1
Divides into external and internal carotid arteries
Left subclavian artery (LSA): 3rd branch of thoracic aorta; originates in Ishimaru zone 2
Yields left vertebral artery
Thoracic aortic arch distal to LSA is Ishimaru zone 3
Descending thoracic aorta beyond arch curvature is Ishimaru zone 4
Further subdivided into 9 subsegments based on thoracic vertebral segments T4-T12
PREPROCEDURE
Indications
Contraindications
Preprocedure Imaging
Getting Started
PROCEDURE
Patient Position/Location
Procedure Steps
Alternative Procedures/Therapies
POST PROCEDURE
Things to Do
Postprocedure Imaging
OUTCOMES
Problems
Complications
Expected Outcomes
Selected References
Loskutov A et al: Endovascular management of chronic type B aortic dissection. Tech Vasc Interv Radiol. 24(2):100752, 2021
Ogawa Y et al: Improved midterm outcomes after endovascular repair of nontraumatic descending thoracic aortic rupture compared with open surgery. J Thorac Cardiovasc Surg. 161(6):2004-12, 2021
Qrareya M et al: Management of postoperative complications following endovascular aortic aneurysm repair. Surg Clin North Am. 101(5):785-98, 2021
Chen SW et al: Complications and management of the thoracic endovascular aortic repair. Aorta (Stamford). 8(3):49-58, 2020
Hundersmarck D et al: Blunt thoracic aortic injury and TEVAR: long-term outcomes and health-related quality of life. Eur J Trauma Emerg Surg. 2020
Qato K et al: Outcomes of thoracic endovascular aneurysm repair (TEVAR) in patients with connective tissue disorders. Vasc Endovascular Surg. 54(8):676-80, 2020
Teraa M et al: Important issues regarding planning and sizing for emergent TEVAR. J Cardiovasc Surg (Torino). 61(6):708-12, 2020
Youssef A et al: Management of the left subclavian artery during TEVAR - complications and mid-term follow-up. Vasa. 47(5):387-92, 2018
Matsuda H: Treatment of uncomplicated type B aortic dissection. Gen Thorac Cardiovasc Surg. 65(2):74-9, 2017
Sweet M et al: A review of new thoracic devices. endovascular today. Reviewed March 8, 2017. Accessed March 8, 2017. http://evtoday.com/pdfs/et1115_F1_Starnes.pdf
von Allmen RS et al: Editor's choice - incidence of stroke following thoracic endovascular aortic repair for descending aortic aneurysm: a systematic review of the literature with meta-analysis. Eur J Vasc Endovasc Surg. 53(2):176-84, 2017
Abraha I et al: Thoracic stent graft versus surgery for thoracic aneurysm. Cochrane Database Syst Rev. CD006796, 2016
Hongku K et al: Total aortic endovascular repair. J Cardiovasc Surg (Torino). 57(6):784-805, 2016
Chung J et al: Left subclavian artery coverage during thoracic endovascular aortic repair and risk of perioperative stroke or death. J Vasc Surg. 54(4):979-84, 2011
Ullery BW et al: Risk factors, outcomes, and clinical manifestations of spinal cord ischemia following thoracic endovascular aortic repair. J Vasc Surg. 54(3):677-84, 2011
Ueda T et al: Incomplete endograft apposition to the aortic arch: bird-beak configuration increases risk of endoleak formation after thoracic endovascular aortic repair. Radiology. 255(2):645-52, 2010
Lee WA: Failure modes of thoracic endografts: prevention and management. J Vasc Surg. 49(3):792-9, 2009
Matsumura JS et al: The Society for Vascular Surgery Practice Guidelines: management of the left subclavian artery with thoracic endovascular aortic repair. J Vasc Surg. 50(5):1155-8, 2009
Greenberg RK et al: Endovascular repair of thoracic aortic lesions with the Zenith TX1 and TX2 thoracic grafts: intermediate-term results. J Vasc Surg. 41(4):589-96, 2005
Leurs LJ et al: Endovascular treatment of thoracic aortic diseases: combined experience from the EUROSTAR and United Kingdom Thoracic Endograft registries. J Vasc Surg. 40(4):670-9; discussion 679-80, 2004
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