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Thoracic Aortic Endografts
Brandt C. Wible, MD; Zubin Irani, MD; T. Gregory Walker, MD, FSIR
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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 & 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, frequent arterial ruptures
                  • Loeys-Dietz syndrome: Phenotypically similar to Ehlers-Danlos type IV subgroup
                  • Marfan syndrome: Cystic medial degeneration; usually involves aortic root (annuloaortic ectasia)
                • Infection (mycotic): Localized infection weakens/compromises integrity of aortic wall
                  • Typically saccular configuration
                  • Organisms seed aorta via lumen/vasa vasorum
                • Pseudoaneurysm: Disruption of 1 or more arterial wall layers; forms contained rupture
                  • May be due to aortic injury following penetrating or blunt trauma (e.g., deceleration injury)
                  • Also associated with infectious, inflammatory, & neoplastic disease
            • Thoracoabdominal aortic aneurysm (TAAA): Extension of TAA distally to involve abdominal aorta
              • Involves visceral arterial segments; highly lethal if untreated but very challenging to treat
            • Thoracic aortic dissection: Intimal tear extends into aortic wall; blood flow separates wall layers
              • Usually originates in thoracic aorta with varied distribution; may extend into abdominal aorta
              • Blood flow separates aortic wall structures, producing "true" & "false" lumina
              • Weakened wall may rupture; high mortality
            • Penetrating atherosclerotic aortic ulcer: Plaque rupture through aortic internal elastic membrane
              • Subsequent intramural hematoma may occur
              • 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 & right subclavian arteries; latter yields vertebral artery
              • Left common carotid artery: 2nd branch of thoracic aorta; originates in Ishimaru zone 1
                • Divides into external & 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 described as Ishimaru zone 3
              • Descending thoracic aorta beyond arch curvature described as Ishimaru zone 4
                • Further subdivided into 9 subsegments based on thoracic vertebral segments T4 to T12

          PREPROCEDURE

          • Indications

            • Contraindications

              • Preprocedure Imaging

                • Getting Started

                  PROCEDURE

                  • Patient Position/Location

                    • Procedure Steps

                      • Alternative Procedures/Therapies

                        POST PROCEDURE

                        • Things to Do

                          • Post Procedure Imaging

                            OUTCOMES

                            • Problems

                              • Complications

                                • Expected Outcomes

                                  Selected References

                                  1. Sweet M, Starnes B: A Review of New Thoracic Devices. Endovascular Today. http://evtoday.com/pdfs/et1115_F1_Starnes.pdf Reviewed March 8, 2017. Accessed March 8, 2017
                                  2. Matsuda H: Treatment of uncomplicated type B aortic dissection. Gen Thorac Cardiovasc Surg. 65(2):74-79, 2017
                                  3. 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):176-184, 2017
                                  4. Abraha I et al: Thoracic stent graft versus surgery for thoracic aneurysm. Cochrane Database Syst Rev. CD006796, 2016
                                  5. Hongku K et al: Total aortic endovascular repair. J Cardiovasc Surg (Torino). 57(6):784-805, 2016
                                  6. 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
                                  7. 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
                                  8. 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
                                  9. Lee WA: Failure modes of thoracic endografts: Prevention and management. J Vasc Surg. 49(3):792-9, 2009
                                  10. 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
                                  11. Kwolek CJ et al: Update on thoracic aortic endovascular grafting using the medtronic talent device. Semin Vasc Surg. 19(1):25-31, 2006
                                  12. 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
                                  13. Chiesa R et al: Ten years experience of thoracic and thoracoabdominal aortic aneurysm surgical repair: lessons learned. Ann Vasc Surg. 18(5):514-20, 2004
                                  14. 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 & 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, frequent arterial ruptures
                                                  • Loeys-Dietz syndrome: Phenotypically similar to Ehlers-Danlos type IV subgroup
                                                  • Marfan syndrome: Cystic medial degeneration; usually involves aortic root (annuloaortic ectasia)
                                                • Infection (mycotic): Localized infection weakens/compromises integrity of aortic wall
                                                  • Typically saccular configuration
                                                  • Organisms seed aorta via lumen/vasa vasorum
                                                • Pseudoaneurysm: Disruption of 1 or more arterial wall layers; forms contained rupture
                                                  • May be due to aortic injury following penetrating or blunt trauma (e.g., deceleration injury)
                                                  • Also associated with infectious, inflammatory, & neoplastic disease
                                            • Thoracoabdominal aortic aneurysm (TAAA): Extension of TAA distally to involve abdominal aorta
                                              • Involves visceral arterial segments; highly lethal if untreated but very challenging to treat
                                            • Thoracic aortic dissection: Intimal tear extends into aortic wall; blood flow separates wall layers
                                              • Usually originates in thoracic aorta with varied distribution; may extend into abdominal aorta
                                              • Blood flow separates aortic wall structures, producing "true" & "false" lumina
                                              • Weakened wall may rupture; high mortality
                                            • Penetrating atherosclerotic aortic ulcer: Plaque rupture through aortic internal elastic membrane
                                              • Subsequent intramural hematoma may occur
                                              • 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 & right subclavian arteries; latter yields vertebral artery
                                              • Left common carotid artery: 2nd branch of thoracic aorta; originates in Ishimaru zone 1
                                                • Divides into external & 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 described as Ishimaru zone 3
                                              • Descending thoracic aorta beyond arch curvature described as Ishimaru zone 4
                                                • Further subdivided into 9 subsegments based on thoracic vertebral segments T4 to T12

                                          PREPROCEDURE

                                          • Indications

                                            • Contraindications

                                              • Preprocedure Imaging

                                                • Getting Started

                                                  PROCEDURE

                                                  • Patient Position/Location

                                                    • Procedure Steps

                                                      • Alternative Procedures/Therapies

                                                        POST PROCEDURE

                                                        • Things to Do

                                                          • Post Procedure Imaging

                                                            OUTCOMES

                                                            • Problems

                                                              • Complications

                                                                • Expected Outcomes

                                                                  Selected References

                                                                  1. Sweet M, Starnes B: A Review of New Thoracic Devices. Endovascular Today. http://evtoday.com/pdfs/et1115_F1_Starnes.pdf Reviewed March 8, 2017. Accessed March 8, 2017
                                                                  2. Matsuda H: Treatment of uncomplicated type B aortic dissection. Gen Thorac Cardiovasc Surg. 65(2):74-79, 2017
                                                                  3. 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):176-184, 2017
                                                                  4. Abraha I et al: Thoracic stent graft versus surgery for thoracic aneurysm. Cochrane Database Syst Rev. CD006796, 2016
                                                                  5. Hongku K et al: Total aortic endovascular repair. J Cardiovasc Surg (Torino). 57(6):784-805, 2016
                                                                  6. 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
                                                                  7. 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
                                                                  8. 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
                                                                  9. Lee WA: Failure modes of thoracic endografts: Prevention and management. J Vasc Surg. 49(3):792-9, 2009
                                                                  10. 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
                                                                  11. Kwolek CJ et al: Update on thoracic aortic endovascular grafting using the medtronic talent device. Semin Vasc Surg. 19(1):25-31, 2006
                                                                  12. 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
                                                                  13. Chiesa R et al: Ten years experience of thoracic and thoracoabdominal aortic aneurysm surgical repair: lessons learned. Ann Vasc Surg. 18(5):514-20, 2004
                                                                  14. 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