Endovascular Treatment of Descending Thoracic Aortic Aneurysms and Dissections

With an estimated incidence of 6 cases per 100,000 population per year, patients with thoracic aortic aneurysms are not infrequently encountered by cardiovascular surgeons, especially as the population ages.1, 29, 30 Traditionally, the only effective treatment of patients with descending thoracic aortic aneurysms has been open surgical aortic graft replacement through a left thoracotomy. Despite efforts to minimize perioperative complications, including earlier operation before rupture, better cardiopulmonary bypass (CPB) circulatory support, and preservation of spinal cord perfusion, the conventional surgical approach continues to be associated with substantial morbidity and mortality in these patients, who are commonly elderly and medically debilitated. One novel technique explored at Stanford University since 1992 is endovascular stent grafting for various types of descending thoracic aortic aneurysms.5, 6, 10, 11, 12, 13, 26, 34 Potentially less traumatic and less expensive than open surgical repair, the use of endovascular stent grafting for patients with descending thoracic aortic aneurysms has now been explored in a few centers around the world. In addition, endovascular catheter-based techniques, such as flap fenestration or stenting, have been used successfully to treat patients with peripheral arterial ischemic complications of aortic dissection, which provides for a quicker, less invasive therapeutic option for these devastating problems.4, 17, 18, 32, 33, 36, 37, 38 This article reviews the authors' initial 5-year experience with stent grafting of descending thoracic aortic disease and with various endovascular modes of treatment of patients with ischemic complications of aortic dissection. At the outset, the authors believe it imperative to emphasize the fundamental importance of surgeons working together with their cardiovascular interventional radiologists (CVIR) or interventional cardiologists in this emerging field; the synergistic, collaborative surgical, and cardiovascular interventional radiologist approach at Stanford University in California is the major reason why their pioneering attempts have been so successful. The surgeons provide the key judgment input in deciding when an intervention is indicated, what type of intervention (open versus endovascular), and in which patients. Surgeons also share in the decision-making process during the procedure, help lay out contingency plans if an untoward event occurs, and take care of the patients after the procedure, when complications can arise; however, the surgeons cannot duplicate the catheter skills and interventional knowledge of the CVIR team. In this context, the authors acknowledge the contributions and support of Michael D. Dake, MD, Suzanne M. Slonim, MD, and their colleagues in the Stanford Division of Cardiovascular and Interventional Radiology in the work presented here. For the sake of the patients, we encourage all surgeons, whether they be cardiac or vascular surgeons, to develop smooth working relationships with their interventional colleagues based on mutual respect and trust. Surgical or cardiovascular interventional radiologist groups trying to do it alone are working in a vacuum (as sadly is the case in many centers around the United States today) and may never attain the same degree of clinical success that is potentially achievable if they work together with their colleagues in a truly multidisciplinary approach.