What care is provided following a thoracic endovascular aortic repair (TEVAR)?

Post-TEVAR Care and Surveillance

Following thoracic endovascular aortic repair (TEVAR), patients require systematic surveillance imaging with CT at 1 month and 12 months post-procedure, and if stable, annually thereafter to monitor for complications and ensure treatment success. 1

Immediate Post-Procedural Care

Initial Recovery Phase

• Patients should be admitted to a post-anesthesia care unit (PACU) or intensive care unit (ICU) with experience in both cardiac surgical and interventional cardiology procedures 1
• Early extubation and mobilization should be prioritized when possible 1
• Careful monitoring of vital parameters including:
  • Hemodynamic stability (blood pressure control is critical)
  • Fluid balance
  • Renal function
  • Atrioventricular conduction 1

Neurological Monitoring

• Regular assessment of lower extremity motor function using a standardized scale:
  • 0: No movement
  • 1: Flicker of movement
  • 2: Able to bend knee to move leg
  • 3: Unable to perform straight leg raise against gravity (may indicate need for neurological evaluation)
  • 4: Normal movement 1
• Any decrease in lower extremity function must be reported immediately as it could represent early and potentially reversible spinal cord ischemia 1

Blood Pressure Management

• Strict blood pressure control is essential to prevent:
  • Stent migration
  • Bleeding from aortic suture lines
  • Spinal cord ischemia (if hypotensive) 1

Imaging Surveillance Protocol

Standard Follow-up Schedule

• Initial imaging at 1 month post-TEVAR (baseline assessment) 1, 2
• Follow-up imaging at 12 months 1
• If stable, annual surveillance thereafter 1
• For patients with residual aortopathy or abnormal findings, more frequent imaging may be necessary 1, 2

Imaging Modalities

• CT is the preferred imaging technique for TEVAR surveillance due to:
  • Better visualization of metallic stent components
  • Higher resolution
  • Ability to detect complications 1, 3
• MRI is a reasonable alternative for:
  • Patients with iodinated contrast allergy
  • Younger patients requiring frequent follow-up (reduces radiation exposure)
  • Patients with renal impairment 1, 2

Monitoring for Complications

Common Complications

• Endoleaks (classified into types I-V)
  • Type I: Proximal or distal attachment site leak
  • Type II: Backfilling through branch vessels
  • Type III: Graft defect or component misalignment
  • Type IV: Graft porosity
  • Type V: Endotension 1
• Retrograde type A aortic dissection
• Stent-graft migration
• Stent-graft fracture or collapse
• Aortic size increase 1, 2

Management of Complications

• Type I and III endoleaks require immediate re-intervention 1
• Type II or V endoleaks with significant sac expansion (≥10 mm) should be considered for re-intervention 1
• If aneurysm sac growth is observed without evidence of type I or III endoleak, CT should be repeated every 6-12 months 1, 2

Special Considerations

Long-term Follow-up

• Reintervention rates after TEVAR range from 7% to 23%, highlighting the importance of continued surveillance 1
• A 6-month follow-up study may be useful for detecting delayed retrograde type A aortic dissection 1
• Patients with heritable thoracic aortic disease require more vigilant surveillance 1, 2

Common Pitfalls to Avoid

• Missing the critical 1-month post-procedure scan, which establishes the baseline 2
• Using inconsistent imaging modalities, which can lead to inaccurate comparisons 2
• Neglecting surveillance in seemingly stable patients 2
• Failing to evaluate adjacent and remote aortic segments, which may develop aneurysmal dilation 2

Transition to Outpatient Care

• When stable, patients should be transferred to a telemetry unit with hemodynamic and electrocardiographic monitoring 1
• Patients should be discharged after a final examination with transthoracic echocardiography 1
• Adequate patient and family education regarding the disease process, importance of blood pressure control, and need for continued follow-up is essential 1

By following this systematic approach to post-TEVAR care and surveillance, complications can be detected early and managed appropriately, improving long-term outcomes and patient survival.