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Thoracic Endovascular Aortic Stent
Repair (TEVAR): Outcomes and
Perioperative Managment Manfred D. Seeberger
EACTA President Department of Anesthesia & Intensive Care
Endovascular Repair of Descending Aortic Disease
Dake et al, N Engl J Med 1994
Endovascular Repair of Descending Aortic Disease
• Stent-graft custom-made for each patient
• Stainless steel endoskeleton
• Z shaped stent elements
• Woven Dacron graft material
Dake et al, N Engl J Med 1994
Endovascular Repair of Descending Aortic Disease
• 13 patients with descending thoracic aortic
aneurysm
• Successful placement in all
• Full (12) or partial thrombosis (1) of aneurysm
• 12 months follow-up
• Surgery after 4 months in 1 patient (dilating arch)
• No deaths
Dake et al, N Engl J Med 1994
Fontes-Carvalho et al, Rev Port Cardiol 2012
Two Decades Later
TEVAR: Full Evidence?
2009
TEVAR technically feasible
Early outcomes↑: paraplegia, mortality, hospital stay
RCT needed: open-conversion, aneurysm exclusion, endoleaks, late mortality?
• TEVAR vs. open surgery in pts with TAA
• All RCT -October 2008, 2 reviewers
No RCT found!
J Thorac Cardiovasc Surg 2011;142:587-94
Cheng et al, J Am Coll Cardiol 2010; 55:986-1001
Hiratzka et al, JACC 2010;55:e27-129
1999-2009
Desai et al, J Thorac Cardiovasc Surg 2011;142:587-94
Other: Type A dissection (40), penetrating ulcer (7), pseudoaneurysm (14)
Desai et al, J Thorac Cardiovasc Surg 2011;142:587-94
• Type A Dissection
• Surgery: Class 1, Level C
• Asymptomatic aneurysm: surgery, if (Class 1, Level C)
• Aortic diameter >5.5 cm
• Marfan / genetic disease at diameter 4-5 cm
• Growth >0.5 cm/yr (even if aorta <5.5 cm)
• Aortic valve surgery and aortic diameter >4.5 cm
Hiratzka et al, JACC 2010;55:e27-129
Recommendations for ascending aortic disease
Aortic Diameter – Risk of Complication
Hiratzka et al, 2010 Guidelines on Thoracic Disease. JACC 2010
Growth rate / yr: 0.1 cm ≤0.2 cm
• Surgery: Class 1, Level C
Hiratzka et al, JACC 2010;55:e27-129
Recommendations for ascending aortic disease
Hiratzka et al, 2010 Guidelines on Thoracic Disease. J Am Coll Cardiol 2010
Cheng et al, J Am Coll Cardiol 2010; 55:986-1001
No single randomized study!
Cheng et al, J Am Coll Cardiol 2010; 55:986-1001
(n=2828)
Cheng et al, J Am Coll Cardiol 2010; 55:986-1001
Cheng et al, J Am Coll Cardiol 2010; 55:986-1001
Cheng et al, J Am Coll Cardiol 2010; 55:986-1001
Cheng et al, J Am Coll Cardiol 2010; 55:986-1001
Cheng et al, J Am Coll Cardiol 2010; 55:986-1001
Cheng et al, J Am Coll Cardiol 2010; 55:986-1001
(n=3060)
Anesthesia for TEVAR
Eur J Anaest 2010;27:91 (abstract)
Anesthesia for TEVAR
• More frequently LA with increased experience
• Promoted by non-surgical access (group A)
• GA: more comfort and security for pts & doctors
• LA: possibly lower morbidity and ICU LOS
The choice of anesthetic techniques and agents
should be tailored to
• individual patient needs
• facilitate surgical and perfusion techniques and
• monitoring of hemodynamics and organ function
Hiratzka et al, JACC 2010;55:e27-129
Recommendations for choice of anesthesia
Descending thoracic aortic aneurysm
• Minimal co-morbidity, diameter >5.5: Surgery (Ib);
• Aneurysm >5.5, degenerative, traumatic; saccular;
postoperative pseudoaneurysm >5.5 cm: TEVAR (1b)
• Thoracoabdminal aneursm >6 cm, TEVAR not
feasible: consider open surgery (1c)
Hiratzka et al, JACC 2010;55:e27-129
Penetrating Ulcer
• No generally agreed first-lime treatment
• Uncomplicated: wait, follow-up
• Complicated by hematoma, pseudoaneurysm
or rupture: treat similar to aortic dissection
in the corresponding segment of the aorta Hiratzka et al, JACC 2010;55:e27-129
Traumatic aortic injury
Jonker et al, J Vasc Surg 2010; 51:565-71
• Conservative treatment: mortality >90%
Traumatic aortic injury
Jonker et al, J Vasc Surg 2010; 51:565-71
