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Thoracic endovascular aortic repair (TEVAR) has emerged as a safe procedure in the treatment of a wide spectrum of descending thoracic aortic pathologies, with satisfactory results both in elective and urgent settings. TEVAR is an effective treatment strategy in thoracic aortic disease. Though emergency repair of the ruptured thoracic aorta still shows high rates of perioperative mortality and morbidity, symptomatic non-ruptured and asymptomatic patients have comparable early outcomes.

Purpose: To compare outcomes of patients treated for pararenal aortic aneurysms using fenestrated endovascular aneurysm repair (fEVAR) vs open surgical repair (OSR) in 3 high-volume centers.Materials and Methods: A multicenter retrospective analysis was conducted of 200 pararenal abdominal aortic aneurysm patients electively treated with OSR (n=108) or fEVAR (n=92) from 1998 to 2015 at 3 tertiary institutions. Endpoints were 30-day morbidity and mortality, late reinterventions, visceral artery occlusion, and mortality. Analysis was conducted on the entire population and on a propensity score-matched population constructed on age, gender, coronary artery disease (CAD), and chronic renal failure.Results: In the total cohort, fEVAR patients were significantly (p<0.001) older and had higher frequencies of CAD (p<0.001) and previous stroke (p=0.003). OSR patients had higher risk of perioperative morbidity (OR 2.5, 95% CI 1.09 to 5.71, p=0.033), specifically respiratory failure (OR 4.06, 95% CI 1.12 to 4.72, p=0.034). These findings were confirmed in the propensity-adjusted analysis, where cardiac complications were also higher after OSR (OR 12.8, 95% CI 0.07 to 0.21, p=0.02). No difference in perioperative mortality (2.2% in fEVAR vs 1.9% in OSR) was identified. Mean follow-up was 50 months (range 0-119). Four-year results showed higher survival (91.2% vs 69.3%, p=0.02) and freedom from reintervention (95.6% vs 77.8%, p=0.01) after OSR in the unmatched population, with a small but significant (p=0.021) difference in the risk of late visceral artery occlusion/stenosis after fEVAR. On propensity analysis, no differences in late survival were found between groups.Conclusion: fEVAR and OSR may afford similar early and midterm survival rates. Higher risks of perioperative systemic complications after OSR are counterbalanced by higher risks of late visceral vessel patency issues and need for reintervention after fEVAR. Both procedures are safe and effective in the long term in experienced centers, where patient evaluation should drive the treatment strategy. [ABSTRACT FROM AUTHOR]

Abstract Background Fascial suture technique (FST) has proved to be a safe and effective access closure technique after endovascular repair of the abdominal aorta. FST has not yet been investigated for closure of large-bore access after thoracic endovascular aortic repair (TEVAR). The aim of this study was to compare FST with open femoral access in terms of access safety, hemostasis efficacy, and reintervention rate after TEVAR. Methods A retrospective study including consecutive patients undergoing TEVAR with either FST or open femoral access between January 2010 and April 2016 was undertaken. Exclusion criteria included the use of closure devices. The composite primary end point was defined as any access-related complication (bleeding, femoral artery stenosis or occlusion, pseudoaneurysm, and wound infection) during 30 postoperative days. Preoperative and procedural variables were examined in a multiple logistic regression model as potential associated factors with access morbidity. All access vessels were postoperatively examined by clinical examination and computed tomography angiography before discharge as well as during the follow-up period. In case of suspected pseudoaneurysm, additional duplex ultrasound and computed tomography angiography confirmed the diagnosis. Results From a total of 206 patients undergoing TEVAR, 109 (53%) had FST, whereas 93 (45%) had an open femoral access. Four patients were excluded: closure device was used in one; one had primary conversion after percutaneous puncture without FST; and in two, no data were available about the femoral access. The access complication rate was higher in FST (FST, 14 [13%]; open access, 3 [3%]; P =.01). Five (4.6%) patients needed early reintervention, two for bleeding and three for vessel occlusion. Seven (6.4%) pseudoaneurysms were detected during the 30-day period in the FST group; three had successful exclusion with thrombin injection, one was treated with manual compression, one was treated with open repair, and two were managed conservatively. Four (3.6%) patients in the FST group and three (3%) patients in the open access group had wound complications. After multiple logistic regression, FST was the only independent factor for any access complication (odds ratio, 5.176; 95% confidence interval, 1.402-19.114; P =.014). During follow-up, neither new pseudoaneurysm nor stenosis or occlusion was detected. Conclusions FST for large-hole closure had higher risk for any access complication compared with open access in TEVAR during the 30-day postoperative period. No other complications during 12 months of follow-up were observed in FST patients. [ABSTRACT FROM AUTHOR]

Thoracic aortic aneurysms are a relatively uncommon disease, with an incidence of 10.4/100 000, with an increase in the last decades, due to the increased quality of vascular screening. Several imaging techniques like thoracic radiography, echocardiography, magnetic resonance (MRI) or positron emission tomography (PET) can be used for the diagnosis of such condition, whose first diagnosis is usually incidental. The gold standard for aneurysm evaluation is computed tomography angiography (CTA), which allows precise diameter assessment and accurate preoperative planning. Advancements in imaging techniques, through electrocardiography (ECG)-gated CTA, permit to avoid movement artifacts and have a more precise definition of proximal aortic segments (aortic arch, ascending aorta).The urgent or emergent treatment of thoracic aneurysms is indicated in symptomatic patients and in case of rupture, respectively. The current European Society for Vascular Surgery guidelines recommend the elective treatment of thoracic aneurysms with a diameter > 55 mm, since diameters of 55 - 60 mm are associated with a rupture risk of 10 %/year. Lower perioperative morbidity and mortality rates have been demonstrated for endovascular repair in comparison with open surgery. According to the current guidelines, the treatment of choice is endovascular, through the implantation of an aortic stent graft (thoracic endovascular aortic repair, TEVAR), while open surgery is reserved to young patients, fit for open surgery. Hybrid procedures, introduced in 2000, include the debranching of supra aortic vessels and TEVAR and are a well established procedure for the treatment of aneurysms involving the aortic arch. The increasing research and expertise in endovascular surgery lead to the development of complex procedures, like chimney TEVAR, fenestrated and branched TEVAR which allowed to reach proximal landing zone to the ascending aorta., Competing Interests: N. Tsilimparis: Proctor für Cook Medical, (© Georg Thieme Verlag KG Stuttgart · New York.)