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European interventionalists are confident about placing stents in patients who present with either acute or chronic thoracic lesions. They are wary, however, at the lack of long-term data about the procedure’s efficacy.
European interventionalists are confident about placing stents in patients who present with either acute or chronic thoracic lesions. They are wary, however, at the lack of long-term data about the procedure's efficacy.
The conventional treatment for a damaged thoracic aorta is surgery, but endovascular repair (EVAR) of traumatic or chronic thoracic problems such as ruptures and aneurysms has proved technically and clinically successful in the short- and midterm. Mortality and morbidity rates are significantly lower than with open surgery.
An important consideration for achieving success with EVAR is careful patient selection and preparation, according to Dr. Luigi Lovato from the University of Bologna in Italy. He cited the need for strict imaging follow-up to obtain reliable long-term results.
Lovato and colleagues achieved successful early and midterm results for 131 patients treated with EVAR for descending thoracic aortic diseases. Indications included type B dissection, atherosclerotic aneurysms, post-traumatic aneurysms, penetrating atherosclerotic ulcers, and pseudoaneurysms.
They achieved technical success in 95% of cases. There were three graft-related deaths, five conversions to surgery, and no cases of paraplegia. Eighteen patients died from nonaortic causes. After a mean follow-up time of 27 months, the remaining patients are alive and well.
Endoleaks, however, are a problem that Lovato called the Achilles heel of endovascular repair. His team had 13 primary and 13 secondary endoleaks, not all successfully treated with EVAR.
"Color Doppler ultrasound is useful to detect primary endoleaks after the endovascular repair," said Dr. Delio Monaco, an interventional radiologist at the University of Parma, Italy.
Monaco and colleagues achieved immediate technical success in 17 patients who had presented with traumatic rupture of the thoracic aorta following motor vehicle accidents. Concomitant injuries included bone fractures, head injuries, lung contusions, and spleen and liver ruptures. Fifteen patients were in the acute phase, two in the chronic phase.
Interventional access was gained in 15 patients through the femoral artery, in one through the external iliac, and in one through the abdominal aorta. Two patients required concomitant procedures for associated cardiovascular or visceral lesions. One patient with a traumatic pseudoaneurysm of the brachiocephalic trunk was treated with aortic and supra-aortic vessel stenting. Stents deployed were either Medtronic or Talent.
Immediate technical success was achieved in all cases. Three deaths not related to stenting occurred within two days of the procedure. The remaining 14 patients are alive and well after almost 2.5 years of follow-up.
"EVAR should be considered the first choice of treatment for acute thoracic rupture," Monaco said.