Toward an Entirely Endovascular World for Thoracoabdominal Aortic Disease: Myth or Reality?

  • Piergiorgio Cao
  • Ciro Ferrer


Endovascular repair (ER) is currently the first-line treatment for the overwhelming majority of aortic disease, and its applicability is expanding to the whole aorta in light of evolving technologies. Whereas with the introduction of new devices developed to overcome common anatomical limitations, techniques of infrarenal (EVAR) and descending thoracic endovascular aneurysm repair (TEVAR) have reached a plateau; the debate is still open on thoracoabdominal aortic aneurysm (TAAA).


  1. 1.
    Mastracci TM, Greenberg RK. Complex aortic disease: changes in perception, evaluation and management. J Vasc Surg. 2008;48(Suppl 6):17S–23S. discussion 23S.CrossRefGoogle Scholar
  2. 2.
    Cheng D, Martin J, Shennib H, et al. Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease a systematic review and meta-analysis of comparative studies. J Am Coll Cardiol. 2010;55(10):986–1001.CrossRefGoogle Scholar
  3. 3.
    Matsumura JS, Rizvi AZ, Society for Vascular Surgery. Left subclavian artery revascularization: Society for Vascular Surgery Practice Guidelines. J Vasc Surg. 2010;52(Suppl 4):65S–70S.CrossRefGoogle Scholar
  4. 4.
    Patel HJ, Nguyen C, Diener AC, Passow MC, Salata D, Deeb GM. Open arch reconstruction in the endovascular era: analysis of 721 patients over 17 years. J Thorac Cardiovasc Surg. 2011;141:1417–23.CrossRefGoogle Scholar
  5. 5.
    Iba Y, Minatoya K, Matsuda H, Sasaki H, Tanaka H, Kobayashi J, et al. Contemporary open aortic arch repair with selective cerebral perfusion in the era of endovascular aortic repair. J Thorac Cardiovasc Surg. 2013;145(3 Suppl):S72–7.CrossRefGoogle Scholar
  6. 6.
    Thomas M, Li Z, Cook DJ, Greason KL, Sundt TM. Contemporary results of open aortic arch surgery. J Thorac Cardiovasc Surg. 2012;144:838–44.CrossRefGoogle Scholar
  7. 7.
    Sachs T, Pomposelli F, Hagberg R, Hamdan A, Wyers M, Giles K, et al. Open and endovascular repair of type B aortic dissection in the Nationwide Inpatient Sample. J Vasc Surg. 2010;52:860–6.CrossRefGoogle Scholar
  8. 8.
    Cowan JA, Dimick JB, Henke PK, Huber TS, Stanley JC, Upchurch GR. Surgical treatment of intact thoracoabdominal aortic aneurysms in the United States: hospital and surgeon volume-related outcomes. J Vasc Surg. 2003;37:1169–74.CrossRefGoogle Scholar
  9. 9.
    Patel VI, Mukhopadhyay S, Ergul E, Aranson N, Conrad MF, Lamuraglia GM, et al. Impact of hospital volume and type on outcomes of open and endovascular repair of descending thoracic aneurysms in the United States Medicare population. J Vasc Surg. 2013;58:346–54.CrossRefGoogle Scholar
  10. 10.
    Chikwe J, Cavallaro P, Itagaki S, Seigerman M, Diluozzo G, Adams DH. National outcomes in acute aortic dissection: influence of surgeon and institutional volume on operative mortality. Ann Thorac Surg. 2013;95:1563–9.CrossRefGoogle Scholar
  11. 11.
    De Rango P, Cao P, Ferrer C, Simonte G, Coscarella C, Cieri E, et al. Aortic arch debranching and thoracic endovascular repair. J Vasc Surg. 2014;59:107–14.CrossRefGoogle Scholar
  12. 12.
    Haulon S, Greenberg RK, Spear R, Eagleton M, Abraham C, Lioupis C, et al. Global experience with an inner branched arch endograft. J Thorac Cardiovasc Surg. 2014;148:1709–16.CrossRefGoogle Scholar
  13. 13.
    Spear R, Haulon S, Ohki T, Tsilimparis N, Kanaoka Y, Milne CP, Debus S, Takizawa R, Kölbel T. Subsequent results for arch aneurysm repair with inner branched endografts. Eur J Vasc Endovasc Surg. 2016;51:380–5.CrossRefGoogle Scholar
  14. 14.
    Spear R, Clough RE, Fabre D, Roeder B, Hertault A, Martin Gonzalez T, Azzaoui R, Sobocinski J, Haulon S. Total endovascular treatment of aortic arch disease using an arch endograft with 3 inner branches. J Endovasc Ther. 2017;24(4):534–8.CrossRefGoogle Scholar
  15. 15.
    Moulakakis KG, Mylonas SN, Dalainas I, Sfyroeras GS, Markatis F, Kotsis T, et al. The chimney-graft technique for preserving supra-aortic branches: a review. Ann Cardiothorac Surg. 2013;2(3):339–46.PubMedPubMedCentralGoogle Scholar
  16. 16.
    McWilliams RG, Murphy M, Hartley D, et al. In situ stent graft fenestration to preserve the left subclavian artery. J Endovasc Ther. 2004;11:170–4.CrossRefGoogle Scholar
  17. 17.
    Manning BJ, Ivancev K, Harris PL. In situ fenestration in the aortic arch. J Vasc Surg. 2010;52:491–4.CrossRefGoogle Scholar
  18. 18.
    Redlinger RE, Ahanchi SS, Panneton JM. In situ laser fenestration during emergent thoracic endovascular aortic repair is an effective method for left subclavian artery revascularization. J Vasc Surg. 2013;58:1171–7.CrossRefGoogle Scholar
  19. 19.
    Kasprzak PM, Kobuch R, Schmid C, Kopp R. Long-term durability of aortic arch in situ stent graft fenestration requiring lifelong surveillance. J Vasc Surg. 2017;65(2):538–41.CrossRefGoogle Scholar
  20. 20.
    Bisdas T, Donas KP, Bosiers M, Torsello G, Austermann M. One-year follow-up after total endovascular repair of a contained-ruptured thoracoabdominal aortic aneurysm with the sandwich technique. J Vasc Surg. 2013;58:673–8.CrossRefGoogle Scholar
  21. 21.
    Bisdas T, Donas KP, Bosiers M, Torsello G, Austermann M. Anatomical suitability of the t-branch stent graft in patients with thoracoabdominal aortic aneurysms treated using custom-made multibranched endografts. J Endovasc Ther. 2013;20:672–7.CrossRefGoogle Scholar
  22. 22.
    Bisdas T, Donas KP, Bosiers MJ, Torsello G, Austermann M. Custom-made versus off-the-shelf multibranched endografts for endovascular repair of thoracoabdominal aortic aneurysms. J Vasc Surg. 2014;60:1186–95.CrossRefGoogle Scholar
  23. 23.
    Criado FJ, McKendrick C, Criado FR. Technical solutions for common problems in TEVAR: managing access and aortic branches. J Endovasc Ther. 2009;16(suppl 1):I63–79.PubMedGoogle Scholar
  24. 24.
    Rockman C. Reducing complications by better case selection: anatomic considerations. Semin Vasc Surg. 2004;17:298–306.CrossRefGoogle Scholar
  25. 25.
    Garcia-Toca M, Eskandari MK. Regulatory TEVAR clinical trials. J Vasc Surg. 2010;52(4 suppl):22S–5S.CrossRefGoogle Scholar
  26. 26.
    Fernandez JD, Craig JM, Garrett HE Jr, et al. Endovascular management of iliac rupture during endovascular aneurysm repair. J Vasc Surg. 2009;50:1293–300.CrossRefGoogle Scholar
  27. 27.
    Arnaoutakis GJ, Schneider EB, Arnaoutakis DJ, et al. Influence of gender on outcomes after thoracic endovascular aneurysm repair. J Vasc Surg. 2014;59:45–51.CrossRefGoogle Scholar
  28. 28.
    Lee WA, Berceli SA, Huber TS, et al. Morbidity with retroperitoneal procedures during endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2003;38:459–63. discussion 464–5.CrossRefGoogle Scholar
  29. 29.
    Melissano G, Tshomba Y, Rinaldi E, Chiesa R. Initial clinical experience with a new low-profile thoracic endograft. J Vasc Surg. 2015;62(2):336–42. Scholar
  30. 30.
    Torsello GF, Inchingolo M, Austermann M, Torsello GB, Panuccio G, Bisdas T. Durability of a low-profile stent graft for thoracic endovascular aneurysm repair. J Vasc Surg. 2017;66(6):1638–43.CrossRefGoogle Scholar
  31. 31.
    Ramanan B, Fernandez CC, Sobel JD, Gasper WJ, Vartanian SM, Reilly LM, Chuter TA, Hiramoto JS. Low-profile versus standard-profile multibranched thoracoabdominal aortic stent grafts. J Vasc Surg. 2016;64(1):39–45.CrossRefGoogle Scholar
  32. 32.
    Maurel B, Delclaux N, Sobocinski J, Hertault A, Martin-Gonzalez T, Moussa M, Spear R, Le Roux M, Azzaoui R, Tyrrell M, Haulon S. The impact of early pelvic and lower limb reperfusion and attentive peri-operative management on the incidence of spinal cord ischemia during thoracoabdominal aortic aneurysm endovascular repair. Eur J Vasc Endovasc Surg. 2015;49(3):248–54.CrossRefGoogle Scholar
  33. 33.
    de Souza LR, Oderich GS, Banga PV, Hofer JM, Wigham JR, Cha S, Gloviczki P. Outcomes of total percutaneous endovascular aortic repair for thoracic, fenestrated, and branched endografts. J Vasc Surg. 2015;62(6):1442.e3–9.e3.CrossRefGoogle Scholar
  34. 34.
    Derrow AE, Seeger JM, Dame DA, Carter RL, Ozaki CK, Flynn TC, Huber TS. The outcome in the United States after thoracoabdominal aortic aneurysm repair, renal artery bypass, and mesenteric revascularization. J Vasc Surg. 2001;34(1):54–61.CrossRefGoogle Scholar
  35. 35.
    Conrad MF, Crawford RS, Davison JK, Cambria RP. Thoracoabdominal aneurysm repair: a 20-year perspective. Ann Thorac Surg. 2007;83(2):S856–61. discussion S890–2.CrossRefGoogle Scholar
  36. 36.
    Coselli JS, Bozinovski J, LeMaire SA. Open surgical repair of 2286 thoracoabdominal aortic aneurysms. Ann Thorac Surg. 2007;83(2):S862–4. discussion S890–2.CrossRefGoogle Scholar
  37. 37.
    Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg. 1993;17(2):357–68. discussion 368–70.CrossRefGoogle Scholar
  38. 38.
    Bensley RP, Curran T, Hurks R, Lo RC, Wyers MC, Hamdan AD, Chaikof EL, Schermerhorn ML. Open repair of intact thoracoabdominal aortic aneurysms in the American College of Surgeons National Surgical Quality Improvement Program. J Vasc Surg. 2013;58(4):894–900.CrossRefGoogle Scholar
  39. 39.
    Tshomba Y, Kahlberg A, Melissano G, Coppi G, Marone E, Ferrari D, Lembo R, Chiesa R. Comparison of renal perfusion solutions during thoracoabdominal aortic aneurysm repair. J Vasc Surg. 2014;59(3):623–33.CrossRefGoogle Scholar
  40. 40.
    Chuter TA, Gordon RL, Reilly LM, Goodman JD, Messina LM. An endovascular system for thoracoabdominal aortic aneurysm repair. J EndovascTher. 2001;8(1):25–33.Google Scholar
  41. 41.
    Greenberg R, Eagleton M, Mastracci T. Branched endografts for thoracoabdominal aneurysms. J Thorac Cardiovasc Surg. 2010;140(6 Suppl):S171–8.CrossRefGoogle Scholar
  42. 42.
    Eagleton MJ, Follansbee M, Wolski K, Mastracci T, Kuramochi Y. Fenestrated and branched endovascular aneurysm repair outcomes for type II and III thoracoabdominal aortic aneurysms. J Vasc Surg. 2016;63(4):930–42.CrossRefGoogle Scholar
  43. 43.
    Oderich GS, Ribeiro M, Reis de Souza L, Hofer J, Wigham J, Cha S. Endovascular repair of thoracoabdominal aortic aneurysms using fenestrated and branched endografts. J Thorac Cardiovasc Surg. 2017;153(2):S32.e7–41.e7.CrossRefGoogle Scholar
  44. 44.
    Verzini F, Loschi D, De Rango P, Ferrer C, Simonte G, Coscarella C, Pogany G, Cao P. Current results of total endovascular repair of thoracoabdominal aortic aneurysms. J Cardiovasc Surg. 2014;55:9–19.Google Scholar
  45. 45.
    Verhoeven EL, Katsargyris A, Bekkema F, Oikonomou K, Zeebregts CJ, Ritter W, Tielliu IF. Ten-year experience with endovascular repair of thoracoabdominal aortic aneurysms: results from 166 consecutive patients. Eur J Vasc Endovasc Surg. 2015;49(5):524–31.CrossRefGoogle Scholar
  46. 46.
    Oikonomou K, Kopp R, Katsargyris A, Pfister K, Verhoeven EL, Kasprzak P. Outcomes of fenestrated/branched endografting in post-dissection thoracoabdominal aortic aneurysms. Eur J Vasc Endovasc Surg. 2014;48(6):641–8.CrossRefGoogle Scholar
  47. 47.
    Reilly LM, Rapp JH, Grenon SM, Hiramoto JS, Sobel J, Chuter TA. Efficacy and durability of endovascular thoracoabdominal aortic aneurysm repair using the caudally directed cuff technique. J Vasc Surg. 2012;56(1):53–63. discussion 63–4.CrossRefGoogle Scholar
  48. 48.
    Mastracci TM, Greenberg RK, Eagleton MJ, Hernandez AV. Durability of branches in branched and fenestrated endografts. J Vasc Surg. 2013;57(4):926–33. Scholar
  49. 49.
    Beach JM, Rajeswaran J, Parodi FE, Kuramochi Y, Brier C, Blackstone E, Eagleton MJ. Survival affects decision making for fenestrated and branched endovascular aortic repair. J Vasc Surg. 2017;67(3):722.e8–34.e8.Google Scholar
  50. 50.
    Lobato AC, Camacho-Lobato L. Endovascular treatment of complex aortic aneurysms using the sandwich technique. J Endovasc Ther. 2012;19:691–706.CrossRefGoogle Scholar
  51. 51.
    Lobato AC. Sandwich technique for aortoiliac aneurysms extending to the internal iliac artery or isolated common/internal iliac artery aneurysms: a new endovascular approach to preserve pelvic circulation. J Endovasc Ther. 2011;18:106–11.CrossRefGoogle Scholar
  52. 52.
    Yoshida R, Yoshida WB, Kolvenbach R, Vieira PR. Modified “stent-graft sandwich” technique for treatment of isolated common iliac artery aneurysm in patient with Marfan syndrome. Ann Vasc Surg. 2012;26:419.PubMedGoogle Scholar
  53. 53.
    Kolvenbach RR, Yoshida R, Pinter L, Zhu Y, Lin F. Urgent endovascular treatment of thoraco-abdominal aneurysms using a sandwich technique and chimney graftsda technical description. Eur J Vasc Endovasc Surg. 2011;41:54–60.CrossRefGoogle Scholar
  54. 54.
    Schwierz E, Kolvenbach RR, Yoshida R, Yoshida W. Experience with the sandwich technique in endovascular thoraco- abdominal aortic aneurysm repair. J Vasc Surg. 2014;59:1562e9.CrossRefGoogle Scholar
  55. 55.
    de Bruin JL, Yeung KK, Niepoth WW, Lely RJ, Cheung Q, de Vries A, et al. Geometric study of various chimney graft configurations in an in vitro juxtarenal aneurysm model. J Endovasc Ther. 2013;20:184–90.CrossRefGoogle Scholar
  56. 56.
    Niepoth WW, de Bruin JL, Yeung KK, Lely RJ, Devrome AN, Wisselink W, et al. A proof-of-concept in vitro study to determine if EndoAnchors can reduce gutter size in chimney graft configurations. J Endovasc Ther. 2013;20:498–505.CrossRefGoogle Scholar
  57. 57.
    Makaroun MS, Dillavou ED, Kee ST, Sicard G, Chaikof E, Bavaria J, Williams D, Cambria RP, Mitchell RS. Endovascular treatment of thoracic aortic aneurysms: results of the phase II multicenter trial of the GORE TAG thoracic endoprosthesis. J Vasc Surg. 2005;41(1):1–9.CrossRefGoogle Scholar
  58. 58.
    Bavaria JE, Appoo JJ, Makaroun MS, Verter J, Yu ZF, Mitchell RS, Gore TAG Investigators. Endovascular stent grafting versus open surgical repair of descending thoracic aortic aneurysms in low-risk patients: a multicenter comparative trial. J Thorac Cardiovasc Surg. 2007;133(2):369–77.CrossRefGoogle Scholar
  59. 59.
    Matsumura JS, Cambria RP, Dake MD, Moore RD, Svensson LG, Snyder S, TX2 Clinical Trial Investigators. International controlled clinical trial of thoracic endovascular aneurysm repair with the Zenith TX2 endovascular graft: 1-year results. J Vasc Surg. 2008;47(2):247–57. discussion 257.CrossRefGoogle Scholar
  60. 60.
    Fairman RM, Criado F, Farber M, Kwolek C, Mehta M, White R, Lee A, Tuchek JM, VALOR Investigators. Pivotal results of the medtronic vascular talent thoracic stent graft system: the VALOR trial. J Vasc Surg. 2008;48(3):546–54.CrossRefGoogle Scholar
  61. 61.
    Greenberg RK, Lu Q, Roselli EE, Svensson LG, Moon MC, Hernandez AV, Dowdall J, Cury M, Francis C, Pfaff K, Clair DG, Ouriel K, Lytle BW. Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques. Circulation. 2008;118(8):808–17. Scholar
  62. 62.
    Ferrer C, Cao P, De Rango P, Tshoma Y, Verzini F, Melissano G, et al. A propensity-matched comparison for endovascular and open repair of thoracoabdominal aortic aneurysms. J Vasc Surg. 2016;63:1201e7.CrossRefGoogle Scholar
  63. 63.
    Austermann M, Donas KP, Panuccio G, Troisi N, Torsello G. Pararenal and thoracoabdominal aortic aneurysm repair with fenestrated and branched endografts: lessons learned and future directions. J Endovasc Ther. 2011;18:157–60.CrossRefGoogle Scholar
  64. 64.
    Haulon S, Greenberg RK. Part two: treatment of type IV thoracoabdominal aneurysmsd fenestrated stent-graft repair is now the best option. Eur J Vasc Endovasc Surg. 2011;42:4–8.CrossRefGoogle Scholar
  65. 65.
    Troisi N, Donas KP, Austermann M, Tessarek J, Umscheid T, Torsello G. Secondary procedures after aortic aneurysm repair with fenestrated and branched endografts. J Endovasc Ther. 2011;18:146–53.CrossRefGoogle Scholar
  66. 66.
    Raux M, Patel VI, Cochennec F, Mukhopadhyay S, Desgranges P, Cambria RP, et al. A propensity-matched comparison of outcomes for fenestrated endovascular aneurysm repair and open surgical repair of complex abdominal aortic aneurysms. J Vasc Surg. 2014;60:858–63.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Piergiorgio Cao
    • 1
  • Ciro Ferrer
    • 2
  1. 1.Mater Dei HospitalRomeItaly
  2. 2.Department of Surgery “Pietro Valdoni”Sapienza University of RomeRomeItaly

Personalised recommendations