Department of Cardiothoracic & Vascular Surgery McGovern Medical School / The University of Texas Health Science Center at Houston

Bruce Tjaden MD

Vascular Surgery Fellow

TEVAR (Thoracic Endovascular Aortic Repair)

for Aneurysm and Dissection

Disclosures

I have no relevant financial disclosures.

Definitions

TEVAR

Definitions

TEVAR – Thoracic Endovascular Aortic Repair

Deploying an impermeable graft on a metal

scaffold (stent-graft) inside the thoracic

aorta to exclude a diseased segment of the

aortic wall from arterial pressure and flow

Definitions

Aneurysm

Dilation of an arterial

segment to >150% of its

normal size

Dissection

Tear in the inner-most

layer of the arterial wall

(intima) allowing blood

flow into a false channel (lumen) blood flow

within the arterial wall

TEVAR for

Aneurysm

Thoracic Aortic Aneurysms

(review)

Can be divided anatomically

into aneurysms involving the

ascending aorta, the

transverse arch, or the

descending aorta.

In general, ascending

aneurysms are treated by

Cardiac surgeons

In general, arch and

descending aneurysms may

be treated by either Vascular

or Cardiac surgeons

Natural History

Risk of rupture directly related to size

5cm = 5.5% risk of rupture or

dissection within 1 yr

5.5cm = 7.2% risk of rupture or

dissection within 1 yr

6cm = 9.3% risk of rupture or

dissection within 1 yr

……..

Descending Thoracic Aortic Aneurysms

TEVAR for Descending Thoracic

Aortic Aneurysms Open Surgical Outcomes

Operative mortality 8.5%

Cardiopulmonary complications 44%

Permanent paraplegia 5%

5 year survival 68%

TEVAR Outcomes

Operative mortality 2%

Cardiopulmonary complications 16%

Permanent paraplegia 1.6%

5 year survival 67%

TEVAR for Descending Thoracic

Aortic Aneurysms

1. Who to treat?

Size >6.0-6.5cm

Rapid growth (>1cm/yr)

Symptoms

Chest pain

Back pain

Compression of adjacent structures (airway)

2. When to treat?

Immediately for rupture

Urgently for symptoms or rapid enlargement

Electively for size criteria

TEVAR for Descending Thoracic

Aortic Aneurysms

TEVAR for Descending Thoracic

Aortic Aneurysms

3. Goals of Repair

Exclude the aneurysm

Land in normal-sized aorta

Minimize risk of spinal ischemia

4. Technique

Lumbar drain placed if possible (unless hostile

back anatomy or rupture with major

hemodynamic instability)

Percutaneous approach usually (no incisions)

Oversize device 10-20%

If coverage of the LSA is required, it is usually

performed only after a pre-emptive LSA

revascularization (transposition or bypass)

TEVAR for Descending Thoracic

Aortic Aneurysms

5. Complications

Spinal Cord Ischemia

Branch vessel coverage end-organ

Ischemia

Stroke

Endoleaks

Retrograde Type A dissection

TEVAR for Descending Thoracic

Aortic Aneurysms

TEVAR for

Dissection

Thoracic Aortic Dissections

Thoracic Aortic Dissections

Acute Dissections

< 2 weeks old

Subacute Dissections

2-12 weeks old

Chronic Dissections

>12 weeks old

Uncomplicated Dissections

No evidence of end-

organ ischemia or

rupture

Complicated

Dissections

Evidence of end-

organ ischemia or

rupture

pick one descriptor from each box

TEVAR for Type B Dissections

Difficult to summarize evidence,

significant heterogeneity (acute,

subacute, chronic, complicated,

uncomplicated)

But in summary

TEVAR is associated with better perioperative

outcomes, similar long term survival, but

increased need for reintervention compared

to open surgery.

TEVAR for Type B Dissections

1. Who to treat?

Medical therapy for uncomplicated dissections

TEVAR for complicated dissections

TEVAR for uncomplicated dissections with high-

risk features

Any aortic diameter >44mm

False lumen diameter >22mm

Age >60

Borderline malperfusion (chronic n/v, ileus, fluctuating pulse

exams, refractory pain, refractory HTN)

TEVAR for Type B Dissections

2. When to treat?

Immediately for acute complicated with

malperfusion or rupture

After 2 weeks for acute uncomplicated

dissections with high risk features (allows septum

to thicken, aorta to stabilize)

As needed for chronic dissections that

degenerate into aneurysms, rupture, or develop

late malperfusion

TEVAR for Type B Dissections

3. Goals of Repair

Close proximal entry tear

Land in normal aorta proximally

Improve true lumen flow / decrease false lumen flow

Promote aortic remodeling

Address malperfusion – fasciotomies, ex-lap, etc.

TEVAR for Type B Dissections

4. Technique

Lumbar drain placed if possible (unless hostile back anatomy or

concern about severity of malperfusion makes it too time-

intensive)

Percutaneous approach usually (no incisions)

Intravascular ultrasound to determine location of tear and aid in

sizing

Minimize device oversizing proximally

Don’t hesitate to cover LSA / down to diaphgram / cover celiac if

needed in order to treat the malperfusion in complicated cases

If required in acute dissections, coverage of the LSA is usually

performed without revascularization during that same operation –

patients are followed postop to determine the need for LSA

bypass / transposition

TEVAR for Type B Dissections

5. Complications

Retrograde Type A dissection

More likely in acute dissections, large aortas, larger proximal

landing zones, bare metal stents proximally, ballooning

Stent-graft Induced New Entry (SINE) tears – tear at trailing edge

of stent-graft leading to more false lumen flow at that location –

may require extension or fenestration

Spinal Cord Ischemia

Branch vessel Ischemia

Stroke

Endoleaks

Persistent False Lumen Flow

References Ray HM, Durham CA, Ocazionez D, Charlton-

Ouw KM, Estrera AL, Miller CC, et al.

Predictors of intervention and mortality in

patients with uncomplicated acute type B

aortic dissection. J Vasc Surg.

2016;64(6):1560–8.

Trimarchi S, Eagle KA, Nienaber CA, Pyeritz

RE, Jonker FHW, Suzuki T, et al. Importance of

refractory pain and hypertension in acute

type B aortic dissection: insights from the

International Registry of Acute Aortic

Dissection (IRAD). Circulation. 2010

Sep;122(13):1283–9.

Thompson M. The VIRTUE registry of type B

thoracic dissections - Study design and early

results. Eur J Vasc Endovasc Surg [Internet].

2011;41(2):159–66. Available from:

http://dx.doi.org/10.1016/j.ejvs.2010.08.016

Heijmen R, Fattori R, Thompson M, Dai-Do D,

Eggebrecht H, Degrieck I, et al. Mid-term

outcomes and aortic remodelling after

thoracic endovascular repair for acute,

subacute, and chronic aortic dissection: The

VIRTUE Registry. Eur J Vasc Endovasc Surg

[Internet]. 2014;48(4):363–71. Available from:

http://dx.doi.org/10.1016/j.ejvs.2014.05.007

Canaud L, Ozdemir BA, Patterson BO, Holt

PJE, Loftus IM, Thompson MM. Retrograde

Aortic Dissection After Thoracic Endovascular

Aortic Repair. Ann Surg [Internet].

2014;260(2):389–95. Available from:

http://content.wkhealth.com/linkback/open

url?sid=WKPTLP:landingpage&an=00000658-

201408000-00030

Liu L, Zhang S, Lu Q, Jing Z, Zhang S, Xu B.

Impact of Oversizing on the Risk of

Retrograde Dissection After TEVAR for Acute

and Chronic Type B Dissection. J Endovasc

Ther [Internet]. 2016;23(4):620–5. Available

from: http://journals.sagepub.com/doi/10.1177/152

6602816647939

Chen Y, Zhang S, Liu L, Lu Q, Zhang T, Jing Z.

Retrograde Type A Aortic Dissection After

Thoracic Endovascular Aortic Repair: A

Systematic Review and Meta-Analysis. J Am

Heart Assoc [Internet]. 2017;6(9):e004649.

Available from:

http://jaha.ahajournals.org/lookup/doi/10.11

61/JAHA.116.004649%0Ahttp://www.ncbi.nlm

.nih.gov/pubmed/28939705%0Ahttp://www.p

ubmedcentral.nih.gov/articlerender.fcgi?arti

d=PMC5634245

Furlough CL, Desai SS, Azizzadeh A, Lawrence

PF. Adjunctive technique for the use of

ProGlide Vascular closure device to improve

hemostasis. J Vasc Surg. 2014;60(6):1693–4.

Estrera AL, Sheinbaum R, Miller CC, Azizzadeh

A, Walkes J-C, Lee T-Y, et al. Cerebrospinal

fluid drainage during thoracic aortic repair:

safety and current management. Ann

Thorac Surg. 2009 Jul;88(1):9–15; discussion

15.

https://www.valleyheartandvascular.com/Th

oracic-Aneurysm-Program/Hybrid-

Procedures.aspx

http://www.huntervascular.com/thoracic-

aortic-aneurysm

http://www.surgery.usc.edu/cvti/graphics/a

orticdissection01.jpg

https://www.inkling.com/read/cronenwett-

rutherfords-vascular-surgery-2-volume-set-

8th/chapter-136

http://circ.ahajournals.org/content/132/17/1

620

Davies RR, Goldstein LJ, Coady MA, Tittle SL,

Rizzo JA, Kopf GS, Elefteriades JA. Yearly

rupture or dissection rates for thoracic

aorticaneurysms: simple prediction based on

size. Ann Thorac Surg. 2002;73:17–27.

Coady MA, Rizzo JA, Hammond GL,

Mandapati D, Darr U, Kopf GS, Elefteriades

JA. What is the appropriate size criterion for resection ofthoracic aortic aneurysms? J

Thorac Cardiovasc Surg. 1997;113:476–491.

https://www.inkling.com/read/cronenwett-

rutherfords-vascular-surgery-2-volume-set-

8th/chapter-138/

https://www.ncbi.nlm.nih.gov/pubmed/2881

1003

http://www.internationaljournalofcardiology.

com/article/S0167-5273(17)34002-0/pdf

https://www.sciencedirect.com/science/arti

cle/pii/S1726490115000039

Thank You

Case #1

A 56 year-old man presented with an

acute complicated TBAD with visceral and

left lower extremity malperfusion.

Medical Therapy?

Open Surgery?

TEVAR?

Treated with

TEVAR.

The pre-TEVAR

images

demonstrate poor

filling of the

mesenteric vessels,

while the post-

TEVAR images

show brisk filling

throughout

the reno-visceral segment as well as

through both iliac

arteries.

Mild preop lactic acidosis resolved.

No laparotomy

required.

Case #2

A 55 year-old woman initially presented

with acute uncomplicated TBAD. She was

managed medically, but developed

renal malperfusion during the subacute

phase, mandating repair.

left subvclavian through retrograde

vertebral flow, exclusion of the diseased

aorta, and brisk distal true lumen filling.

She was followed expectantly, and did

not require left subclavian

revascularization.

Case #2

TEVAR

During TEVAR,

angiography

revealed interval

development of

a contained

rupture (left

image). IVUS

confirmed the

dissection

extended into the

distal aortic arch.

Case #2 The operative plan was

modified, and an

endograft was deployed with intentional left

subclavian artery

coverage. Completion

angiogram revealed adequate filling of the

left subvclavian through

retrograde vertebral

flow, exclusion of the

diseased aorta, and brisk

distal true lumen filling

(right image). She was

followed expectantly,

and did not require left subclavian

revascularization.

Case #2 The operative plan was

modified, and an

endograft was deployed with intentional left

subclavian artery

coverage. Completion

angiogram revealed adequate filling of the

left subvclavian through retrograde vertebral flow,

exclusion of the diseased

aorta, and brisk distal

true lumen filling (right

image). She was

followed expectantly,

and did not require left subclavian

revascularization.

Case #3

67M w/ Symptomatic Descending

Thoracic Aortic Aneurysm beginning at

the distal edge of the left subclavian

artery.

Prior EVAR with bilateral internal iliac

artery occlusions.

Medical therapy?

Open surgery?

TEVAR with LSA coverage alone?

TEVAR with LSA coverage and revasc?

Case #3

TEVAR w/ LCCLSA bypass and plug

Case #4

85F w/ descending thoracic aortic

aneurysm - ?world record?

Case #4

TEVAR w/ extensive spinal coverage – no spinal

ischemia – LD removed POD#1 – d/c’d home.

References Ray HM, Durham CA, Ocazionez D, Charlton-

Ouw KM, Estrera AL, Miller CC, et al.

Predictors of intervention and mortality in

patients with uncomplicated acute type B

aortic dissection. J Vasc Surg.

2016;64(6):1560–8.

Trimarchi S, Eagle KA, Nienaber CA, Pyeritz

RE, Jonker FHW, Suzuki T, et al. Importance of

refractory pain and hypertension in acute

type B aortic dissection: insights from the

International Registry of Acute Aortic

Dissection (IRAD). Circulation. 2010

Sep;122(13):1283–9.

Thompson M. The VIRTUE registry of type B

thoracic dissections - Study design and early

results. Eur J Vasc Endovasc Surg [Internet].

2011;41(2):159–66. Available from:

http://dx.doi.org/10.1016/j.ejvs.2010.08.016

Heijmen R, Fattori R, Thompson M, Dai-Do D,

Eggebrecht H, Degrieck I, et al. Mid-term

outcomes and aortic remodelling after

thoracic endovascular repair for acute,

subacute, and chronic aortic dissection: The

VIRTUE Registry. Eur J Vasc Endovasc Surg

[Internet]. 2014;48(4):363–71. Available from:

http://dx.doi.org/10.1016/j.ejvs.2014.05.007

Canaud L, Ozdemir BA, Patterson BO, Holt

PJE, Loftus IM, Thompson MM. Retrograde

Aortic Dissection After Thoracic Endovascular

Aortic Repair. Ann Surg [Internet].

2014;260(2):389–95. Available from:

http://content.wkhealth.com/linkback/open

url?sid=WKPTLP:landingpage&an=00000658-

201408000-00030

Liu L, Zhang S, Lu Q, Jing Z, Zhang S, Xu B.

Impact of Oversizing on the Risk of

Retrograde Dissection After TEVAR for Acute

and Chronic Type B Dissection. J Endovasc

Ther [Internet]. 2016;23(4):620–5. Available

from: http://journals.sagepub.com/doi/10.1177/152

6602816647939

Chen Y, Zhang S, Liu L, Lu Q, Zhang T, Jing Z.

Retrograde Type A Aortic Dissection After

Thoracic Endovascular Aortic Repair: A

Systematic Review and Meta-Analysis. J Am

Heart Assoc [Internet]. 2017;6(9):e004649.

Available from:

http://jaha.ahajournals.org/lookup/doi/10.11

61/JAHA.116.004649%0Ahttp://www.ncbi.nlm

.nih.gov/pubmed/28939705%0Ahttp://www.p

ubmedcentral.nih.gov/articlerender.fcgi?arti

d=PMC5634245

Furlough CL, Desai SS, Azizzadeh A, Lawrence

PF. Adjunctive technique for the use of

ProGlide Vascular closure device to improve

hemostasis. J Vasc Surg. 2014;60(6):1693–4.

Estrera AL, Sheinbaum R, Miller CC, Azizzadeh

A, Walkes J-C, Lee T-Y, et al. Cerebrospinal

fluid drainage during thoracic aortic repair:

safety and current management. Ann

Thorac Surg. 2009 Jul;88(1):9–15; discussion

15.

https://www.valleyheartandvascular.com/Th

oracic-Aneurysm-Program/Hybrid-

Procedures.aspx

http://www.huntervascular.com/thoracic-

aortic-aneurysm

http://www.surgery.usc.edu/cvti/graphics/a

orticdissection01.jpg

https://www.inkling.com/read/cronenwett-

rutherfords-vascular-surgery-2-volume-set-

8th/chapter-136

http://circ.ahajournals.org/content/132/17/1

620

Davies RR, Goldstein LJ, Coady MA, Tittle SL,

Rizzo JA, Kopf GS, Elefteriades JA. Yearly

rupture or dissection rates for thoracic

aorticaneurysms: simple prediction based on

size. Ann Thorac Surg. 2002;73:17–27.

Coady MA, Rizzo JA, Hammond GL,

Mandapati D, Darr U, Kopf GS, Elefteriades

JA. What is the appropriate size criterion for resection ofthoracic aortic aneurysms? J

Thorac Cardiovasc Surg. 1997;113:476–491.

https://www.inkling.com/read/cronenwett-

rutherfords-vascular-surgery-2-volume-set-

8th/chapter-138/

https://www.ncbi.nlm.nih.gov/pubmed/2881

1003

http://www.internationaljournalofcardiology.

com/article/S0167-5273(17)34002-0/pdf

https://www.sciencedirect.com/science/arti

cle/pii/S1726490115000039

Thank You