Techniques for large sheath insertion during endovascular thoracic aortic aneurysm repair

Despite improvements in operative technique and perioperative management, conventional open repair of descending thoracic aortic aneurysms (DTAs) continues to be associated with significant morbidity and a perioperative mortality between 4.8% and 20%, which may be even more pronounced in the acute setting. Since the first description of the endovascular repair of a thoracic aortic aneurysm by Dake et al, several studies have shown the safety of this approach, as well as possible decreases in perioperative mortality and complications, most notably paraplegia. Because of the less invasive nature and likely improved perioperative outcomes of endovascular repair of DTA, this is rapidly becoming the favored approach for management in these patients. Many patients, however, continue to be ineligible because of suboptimal vascular access, aortic arch angulation, and landing zone inadequacies. Although industry has been working to solve the last two issues, vascular access continues to be of major concern because delivery systems remain excessively large. In the United States, the currently available endografts for thoracic aorta aneurysms require delivery sheaths ranging from 20F to 25F, depending on the size of the graft and the manufacturer (Table). Despite these challenges, with the recent approval by the US Food and Drug Administration of the Gore Thoracic Aortic Graft endoprosthesis (W.L. Gore and Associates, Inc, Flagstaff, Ariz) and the ongoing evaluation of the Talent (Medtronic, Santa Rosa, Calif) and Zenith TX1 and TX2 (Cook Inc, Bloomington, Ind) endografts, it is clear that this technology is moving forward. With more widespread use and continued innovation, industry should be able to overcome the difficulties currently encountered with vascular access for the introduction of thoracic aortic endografts. Until that time, however, one should be knowledgeable of and comfortable with the implementation of several adjunctive maneuvers that may allow graft placement in otherwise ineligible patients. Furthermore, a thorough knowl