Thoracic endovascular aortic repair (TEVAR) is an alternative to open repair for patients with suitable anatomy offering a less invasive approach that has short- and intermediate-term benefits including decreased mortality, freedom from aneurysm-related morbidity, and hospital length of stay. After 5 years, however, the survival advantage with TEVAR is no longer demonstrated. Candidates for endovascular repair are patients who meet the criteria for intervention, have anatomy suitable for endovascular repair, have comorbidities associated with increased morbidity and mortality, and lack aortopathy related to connective tissue disorders. In recent years, aortic stent grafting has undergone a significant liberalization in its use for many aortic pathologies. In addition to the repair of TAAs, many centers are now treating complicated TBADs, traumatic aortic injuries, IMHs, and penetrating aortic ulcers via the endovascular approach.

The goal of endovascular aortic repair is to affix the stent graft to nonaneurysmal aortic or iliac segments, excluding blood flow to the aneurysm sac. TEVAR is currently only approved by the U.S. Food and Drug Administration (FDA) for interventions involving the descending thoracic, juxtarenal, and infrarenal aortic segments. The application of endovascular stenting to the ascending arch or thoracoabdominal aortic segments is not currently approved due to the increased risk of aneurysmal sac enlargement. Application of endovascular stenting to these segments may be performed as an investigational device exemption or expanded access.

Patient characteristics associated with increased morbidity and mortality following open TAAA repair include advanced age, CKD greater than or equal to Stage 3, COPD with FEV₁ less than or equal to 50%, and those with a history of a cerebral vascular event. TEVAR may be considered in these patients as an alternative to open repair despite suboptimal anatomy for endovascular repair. Relative contraindications to TEVAR include mycotic aneurysms, aneurysms secondary to connective tissue disease (MFS, Ehlers-Danlos syndrome [EDS], etc), and aneurysms extending proximal to the LSCA. Connective tissue disease also presents a relative contraindication due to concern for the longevity of the endovascular repair in this patient population. In certain instances, "hybrid" procedures, which consist of debranching of the visceral arterial supply followed by endovascular repair of the aneurysm, can also be considered.

The major advantages of endovascular repair include short- and intermediate-term reduced morbidity and mortality and hospital length of stay. Additionally, the outcome benefits of open repair are limited to high-volume centers, so TEVAR offers increased access and feasibility for aortic repair at low-volume centers. The major disadvantages of TEVAR include loss of survival advantage after 5 years and a significantly higher reintervention rate compared to open repair.

References

• Harik L, Lau C. Open and endovascular repair of thoracoabdominal aortic aneurysm-a narrative review. J Thorac Dis. 2023;15:3984-3997.
• Isselbacher EM, Preventza O, Hamilton Black J 3rd, et al; Peer Review Committee Members. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2022;146:e334-e482.
• Lau C, Soletti GJ, Lawrence KM, et al. Contemporary outcomes of open repair of acute complicated type B aortic dissection. J Vasc Surg. 2023;78:593-601.e4.