From the Guidelines
Thoracic Endovascular Aortic Repair (TEVAR) is indicated for patients with unruptured descending thoracic aortic aneurysms (DTA) ≥55 mm in diameter, and is preferred over open repair when anatomy is suitable. This recommendation is based on the most recent guidelines from the European Heart Journal, which suggest that TEVAR is a recommended treatment option for patients with unruptured DTA aneurysms ≥55 mm in diameter, without heritable thoracic aortic disease (HTAD) 1.
Indications for TEVAR
The indications for TEVAR include:
- Unruptured DTA aneurysms ≥55 mm in diameter
- Unruptured degenerative thoracoabdominal aortic aneurysms (TAAA) ≥60 mm in diameter
- Patients with DTA aneurysms who undergo TEVAR with planned left subclavian artery (LSA) coverage, and require revascularization of the LSA before TEVAR to reduce the risk of spinal cord ischemia and stroke
- TAAA with high-risk features, such as rapid aortic growth, symptomatic aneurysms, or underlying connective tissue disorder, may require repair at a smaller diameter threshold
Patient Selection
Patient selection for TEVAR requires consideration of anatomical factors, including:
- Adequate landing zones (typically 2 cm of healthy aorta proximal and distal to the lesion)
- Appropriate access vessel size
- Absence of prohibitive angulation
- Suitability for endovascular repair using fenestrated and/or branched endografts in experienced centers
Long-term Surveillance
Long-term surveillance with CT or MRI imaging is essential following TEVAR to monitor for endoleaks, device migration, or progression of aortic disease 1. This allows for early detection and treatment of potential complications, and helps to improve patient outcomes.
Recommendation
TEVAR is a recommended treatment option for patients with unruptured DTA aneurysms ≥55 mm in diameter, and is preferred over open repair when anatomy is suitable. This recommendation is based on the most recent guidelines and evidence, which suggest that TEVAR is associated with lower perioperative mortality, reduced complication rates, and faster recovery times compared to open repair 1.
From the Research
Indications for Thoracic Endovascular Aortic Repair (TEVAR)
TEVAR is indicated for the treatment of various thoracic aortic pathologies, including:
- Descending thoracic aortic aneurysms (TAA) 2, 3, 4
- Thoracic aortic dissections, including acute and chronic type B aortic dissections (TBAD) 5
- Traumatic injuries of the thoracic aorta 2
- Other rarer pathologic processes of the descending thoracic aorta (DTA) 2
Patient Selection
The decision to perform TEVAR should be based on anatomic eligibility rather than patient-specific factors, as is the case in open TAA repair 2. However, patient characteristics, such as age, comorbidities, and overall health status, should be taken into account when deciding between TEVAR and open surgical repair (OSR) 6.
Benefits of TEVAR
TEVAR has been shown to have several benefits over open surgical repair, including:
- Lower morbidity and mortality rates 2, 3, 4
- Reduced length of stay and shorter recovery time 2
- Lower risk of complications, such as paralysis, paraparesis, and renal failure 2, 3
- Improved perioperative and short-term outcomes 2, 3, 4
Imaging and Follow-up
Imaging plays a crucial role in the diagnosis and follow-up of patients undergoing TEVAR. Recommendations include:
- Urgent imaging, usually computed tomography angiography (CTA), for patients considered at high risk for symptomatic TAA or acute aortic syndrome 2
- Fine-cut (≤0.25 mm) CTA of the entire aorta, as well as the iliac and femoral arteries, for preoperative planning 2
- Routine use of three-dimensional centerline reconstruction software for accurate case planning and execution in TEVAR 2
- Contrast-enhanced computed tomography scanning at 1 month and 12 months after TEVAR, and then yearly for life, with consideration of more frequent imaging if an endoleak or other abnormality of concern is detected 2