Endovascular Treatment of Aortic Diseases

  • Andreas Mitsis
  • Christoph A. NienaberEmail author


Diseases of the aorta include a wide spectrum of acute and chronic conditions ranging from aortic aneurysms and malformations to acute aortic syndromes (AAS), including acute aortic dissection (AD), intramural haematoma (IMH), penetrating aortic ulcer (PAU) and even traumatic aortic injury (TAI). Furthermore, pseudoaneurysm, atherosclerotic and inflammatory conditions can affect the aorta at any location. High risk for acute aortic syndrome and for congenital abnormalities including coarctation of the aorta is often associated with syndromic features and hereditary genetic underpinnings. Classic surgical strategies were for many years the gold standard to treat many aortic conditions; the last two decades, however, has seen the emergence of less traumatic endovascular management as an additional or alternative option to classic surgical strategies. In particular scenarios, endovascular management has already replaced open surgery, while the complexity of the underlying vascular disease, the comorbidity and the increasing age of patients render this cohort very special. Therefore, every patient with aortic disease should be discussed by a dedicated aortic team of specialists that normally consists of vascular interventionalists (cardiology or radiology) and surgeons (cardiac or cardiothoracic) and dedicated anaesthesiologists with the idea to offer the individually best approach to a complex problem: the team should at the same time cover screening for aortic disease and follow-up after surgery or intervention at a personal level.


Acute aortic syndromes Aortic dissection Intramural haematoma Penetrating aortic ulcer Traumatic aortic injury Thoracic aortic aneurysms Endovascular treatment 


  1. 1.
    Erbel R, Aboyans V, Boileau C, Bossone E, Di Bartolomeo R, Eggebrecht H, et al. Authors/task force members. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases. Eur Heart J. 2015;36:2779.CrossRefGoogle Scholar
  2. 2.
    Meszaros I, Morocz J, Szlavi J, Schmidt J, Tornoci L, Nagy L, et al. Epidemiology and clinicopathology of aortic dissection. Chest. 2000;117:1271–8.CrossRefGoogle Scholar
  3. 3.
    Clouse WD, Hallett JW Jr, Schaff HV, Spittell PC, Rowland CM, Ilstrup DM, et al. Acute aortic dissection: population-based incidence compared with degenerative aortic aneurysm rupture. Mayo Clin Proc. 2004;79:176–80.CrossRefGoogle Scholar
  4. 4.
    Mehta RH, et al. Chronobiological patterns of acute aortic dissection. Circulation. 2002;106:1110–5.CrossRefGoogle Scholar
  5. 5.
    Landenhed M, et al. Risk profiles for aortic dissection and ruptured or surgically treated aneurysms: a prospective cohort study. J Am Heart Assoc. 2015;4:e001513.CrossRefGoogle Scholar
  6. 6.
    Nienaber CA, Clough RE, Sakalihasan N, Suzuki T, Gibbs R, Mussa F, et al. Aortic dissection. Nat Rev Dis Primers. 2016;2:16071.CrossRefGoogle Scholar
  7. 7.
    VIRTUE Registry Investigators. Mid-term outcomes and aortic remodelling after thoracic endovascular repair for acute, subacute, and chronic aortic dissection: the VIRTUE Registry. Eur J Vasc Endovasc Surg. 2014;48:363–71.CrossRefGoogle Scholar
  8. 8.
    Trimarchi S, Eagle KA, Nienaber CA, et al. Role of age in acute type A aortic dissection outcome: report from the International Registry of Acute Aortic Dissection (IRAD). J Thorac Cardiovasc Surg. 2010;140:784–9.CrossRefGoogle Scholar
  9. 9.
    Nienaber CA, Fattori R, Lund G, et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med. 1999;340:1539–45.CrossRefGoogle Scholar
  10. 10.
    Dake MD, Kato N, Mitchell RS, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med. 1999;340:1546–52.CrossRefGoogle Scholar
  11. 11.
    Chiappini B, et al. Early and late outcomes of acute type A aortic dissection: analysis of risk factors in 487 consecutive patients. Eur Heart J. 2005;26:180–6.CrossRefGoogle Scholar
  12. 12.
    Trimarchi S, et al. Contemporary results of surgery in acute type A aortic dissection: the International Registry of Acute Aortic Dissection experience. J Thorac Cardiovasc Surg. 2005;129:112–22.CrossRefGoogle Scholar
  13. 13.
    Tang GH, et al. Surgery for acute type A aortic dissection in octogenarians is justified. J Thorac Cardiovasc Surg. 2013;145:S186–90.CrossRefGoogle Scholar
  14. 14.
    Weigang E, Parker JA, Czerny M, Lonn L, Bonser RS, Carrel T, et al. Should intentional endovascular stent-graft coverage of the left subclavian artery be preceded by prophylactic revascularisation? Eur J Cardiothorac Surg. 2011;40:858–68.PubMedGoogle Scholar
  15. 15.
    Eggebrecht H, Thompson M, Rousseau H, Czerny M, Lönn L, Mehta RH, Erbel R, European Registry on Endovascular Aortic Repair Complications. Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: insight from the European registry on endovascular aortic repair complications. Circulation. 2009;120:S276–81.CrossRefGoogle Scholar
  16. 16.
    Midulla M, Renaud A, Martinelli T, Koussa M, Mounier-Vehier C, Prat A, Beregi JP. Endovascular fenestration in aortic dissection with acute malperfusion syndrome: immediate and late follow-up. J Thorac Cardiovasc Surg. 2011;142:66–72.CrossRefGoogle Scholar
  17. 17.
    Nienaber CA, Sakalihasan N, Clough RE, Aboukoura M, Mancuso E, Yeh JS, et al. Thoracic endovascular aortic repair (TEVAR) in proximal (type A) aortic dissection: ready for a broader application? J Thorac Cardiovasc Surg. 2017;153:S3–11.CrossRefGoogle Scholar
  18. 18.
    Shrestha M, Martens A, Kruger H, Maeding I, Ius F, Fleissner F, Haverich A. Total aortic arch replacement with the elephant trunk technique: single-Centre 30-year results. Eur J Cardiothorac Surg. 2014;45:289–96.CrossRefGoogle Scholar
  19. 19.
    Roselli EE, Rafael A, Soltesz EG, Canale L, Lytle BW. Simplified frozen elephant trunk repair for acute DeBakey type I dissection. J Thorac Cardiovasc Surg. 2013;145:S197–201.CrossRefGoogle Scholar
  20. 20.
    Jakob H, Dohle DS, Piotrowski J, Benedik J, Thielmann M, Marggraf G, Erbel R, Tsagakis K. Six-year experience with a hybrid stent graft prosthesis for extensive thoracic aortic disease: an interim balance. Eur J Cardiothorac Surg. 2012;42:1018–25.CrossRefGoogle Scholar
  21. 21.
    Cao P, De Rango P, Czerny M, Evangelista A, Fattori R, Nienaber C, Rousseau H, Schepens M. Systematic review of clinical outcomes in hybrid procedures for aortic arch dissections and other arch diseases. J Thorac Cardiovasc Surg. 2012;144:1286–300.CrossRefGoogle Scholar
  22. 22.
    Eggebrecht H, Nienaber CA, Neuhäuser M, et al. Endovascular stent-graft placement in aortic dissection: a meta-analysis. Eur Heart J. 2006;27:489–98.CrossRefGoogle Scholar
  23. 23.
    Fattori R, Cao P, De Rango P, Czerny M, Evangelista A, Nienaber C, et al. Interdisciplinary expert consensus document on management of type B aortic dissection. J Am Coll Cardiol. 2013;61:1661–78.CrossRefGoogle Scholar
  24. 24.
    Onitsuka S, Akashi H, Tayama K, Okazaki T, Ishihara K, Hiromatsu S, et al. Long-term outcome and prognostic predictors of medically treated acute type B aortic dissections. Ann Thorac Surg. 2004;78:1268–73.CrossRefGoogle Scholar
  25. 25.
    Fattori R, Tsai TT, Myrmel T, Evangelista A, Cooper JV, Trimarchi S, et al. Complicated acute type B dissection: is surgery still the best option? A report from the International Registry of Acute Aortic Dissection. JACC Cardiovasc Interv. 2008;1:395–402.CrossRefGoogle Scholar
  26. 26.
    Grabenwöger M, Alfonso F, Bachet J, Bonser R, Czerny M, Eggebrecht H, European Association for Cardio-Thoracic Surgery (EACTS); European Society of Cardiology (ESC); European Association of Percutaneous Cardiovascular Interventions (EAPCI), et al. Thoracic Endovascular Aortic Repair (TEVAR) for the treatment of aortic diseases: a position statement from the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg. 2012;42:17–24.CrossRefGoogle Scholar
  27. 27.
    Acosta S, Blomstrand D, Gottsater A. Epidemiology and long-term prognostic factors in acute type B aortic dissection. Ann Vasc Surg. 2007;21:415–22.CrossRefGoogle Scholar
  28. 28.
    Brunkwall J, Kasprzak P, Verhoeven E, et al. Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial. Eur J Vasc Endovasc Surg. 2014;48:285–91.CrossRefGoogle Scholar
  29. 29.
    NienaberCA RH, Eggebrecht H, Kische S, Fattori R, Rehders TC, et al. Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial. Circulation. 2009;120:2519–28.CrossRefGoogle Scholar
  30. 30.
    Nienaber CA, Kische S, Rousseau H, Eggebrecht H, Rehders TC, Kundt G, et al. INSTEAD-XL trial. Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Interv. 2013;6:407–16.CrossRefGoogle Scholar
  31. 31.
    Wolff KA, Herold CJ, Tempany CM, et al. Aortic dissection: atypical patterns seen at MR imaging. Radiology. 1991;181:489–95.CrossRefGoogle Scholar
  32. 32.
    Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management: part II: therapeutic management and follow-up. Circulation. 2003;108:772–8.CrossRefGoogle Scholar
  33. 33.
    Evangelista A, et al. Acute intramural hematoma of the aorta: a mystery in evolution. Circulation. 2005;111:1063–70.CrossRefGoogle Scholar
  34. 34.
    Evangelista A, Czerny M, Nienaber C, Schepens M, Rousseau H, Cao P, Moral S, Fattori R. Interdisciplinary expert consensus on management of type B intramural haematoma and penetrating aortic ulcer. Eur J Cardiothorac Surg. 2015;47:209–17.CrossRefGoogle Scholar
  35. 35.
    Nathan DP, et al. Presentation, complications, and natural history of penetrating atherosclerotic ulcer disease. J Vasc Surg. 2012;55:10–5.CrossRefGoogle Scholar
  36. 36.
    Robertson MM, et al. A double-blind controlled comparison of fluoxetine and lofepramine in major depressive illness. J Psychopharmacol. 1994;8:98–103.CrossRefGoogle Scholar
  37. 37.
    Ganaha F, et al. Prognosis of aortic intramural hematoma with and without penetrating atherosclerotic ulcer: a clinical and radiological analysis. Circulation. 2002;106:342–8.CrossRefGoogle Scholar
  38. 38.
    Coady MA, Rizzo JA, Elefteriades JA. Pathologic variants of thoracic aortic dissections: penetrating atherosclerotic ulcers and intramural hematomas. Cardiol Clin. 1999;17:637–57.CrossRefGoogle Scholar
  39. 39.
    Movsowitz HD, Lampert C, Jacobs LE, et al. Penetrating atherosclerotic aortic ulcers. Am Heart J. 1994;128:1210–7.CrossRefGoogle Scholar
  40. 40.
    Richens D, Kotidis K, Neale M, et al. Rupture of the aorta following road traffic accidents in the United Kingdom 1992–1999: the results of the co-operative crash injury study. Eur J Cardiothorac Surg. 2003;23:143–8.CrossRefGoogle Scholar
  41. 41.
    Kodali S, Jamieson WR, Leia-Stephens M, Miyagishima RT, Janusz MT, Tyers GF. Traumatic rupture of the thoracic aorta. A 20-year review: 1969–1989. Circulation. 1991;84:S40–6.CrossRefGoogle Scholar
  42. 42.
    Hunt JP, Baker CC, Lentz CW, Rutledge RR, Oller DW, Flowe KM, et al. Thoracic aorta injuries: management and outcome of 144 patients. J Trauma. 1996;40:547–55.CrossRefGoogle Scholar
  43. 43.
    Rousseau H, Soula P, Perreault P, et al. Delayed treatment of traumatic rupture of the thoracic aorta with endoluminal covered stent. Circulation. 1999;99:498–504.CrossRefGoogle Scholar
  44. 44.
    Scheinert D, Krankenberg H, Schmidt A, et al. Endoluminal stent-graft placement for acute rupture of the descending thoracic aorta. Eur Heart J. 2004;25:694–700.CrossRefGoogle Scholar
  45. 45.
    Demers P, Miller C, Scott Mitchell R, et al. Chronic traumatic aneurysms of the descending thoracic aorta: mid-term results of endovascular repair using first and second-generation stent-grafts. Eur J Cardiothorac Surg. 2004;25:394–400.CrossRefGoogle Scholar
  46. 46.
    Hultgren R, Larsson E, Wahlgren CM, Swedenborg J. Female and elderly abdominal aortic aneurysm patients more commonly have concurrent thoracic aortic aneurysm. Ann Vasc Surg. 2012;26:918–23.CrossRefGoogle Scholar
  47. 47.
    Chaer RA, et al. Synchronous and metachronous thoracic aneurysms in patients with abdominal aortic aneurysms. J Vasc Surg. 2012;56:1261–5.CrossRefGoogle Scholar
  48. 48.
    Karthikesalingam A, et al. The shortfall in long-term survival of patients with repaired thoracic or abdominal aortic aneurysms: retrospective case-control analysis of hospital episode statistics. Eur J Vasc Endovasc Surg. 2013;46:533–41.CrossRefGoogle Scholar
  49. 49.
    Davies RR, Gallo A, Coady MA, Tellides G, Botta DM, Burke B, Coe MP, Kopf GS, Elefteriades JA. Novel measurement of relative aortic size predicts rupture of thoracic aortic aneurysms. Ann Thorac Surg. 2006;81:169–77.CrossRefGoogle Scholar
  50. 50.
    Muhs BE, et al. Dynamic cine-CT angiography for the evaluation of the thoracic aorta; insight in dynamic changes with implications for thoracic endograft treatment. Eur J Vasc Endovasc Surg. 2006;32:532–6.CrossRefGoogle Scholar
  51. 51.
    Elefteriades J. Natural history of thoracic aortic aneurysms: indications for surgery, and surgical versus nonsurgical risks. Ann Thorac Surg. 2002;74:S1877–80.CrossRefGoogle Scholar
  52. 52.
    Perreas K, Samanidis G, Dimitriou S, Kalogris P, Balanika M, Antzaka C, Khoury M, Michalis A. Outcomes after ascending aorta and proximal aortic arch repair using deep hypothermic circulatory arrest with retrograde cerebral perfusion: analysis of 207 patients. Interact Cardiovasc Thorac Surg. 2012;15:456–61.CrossRefGoogle Scholar
  53. 53.
    Walsh SR, et al. Endovascular stenting versus open surgery for thoracic aortic disease: systematic review and meta-analysis of perioperative results. J Vasc Surg. 2008;47:1094–8.CrossRefGoogle Scholar
  54. 54.
    Cheng D, 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;55:986–1001.CrossRefGoogle Scholar
  55. 55.
    Bavaria JE, et al. 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;133:369–77.CrossRefGoogle Scholar
  56. 56.
    Makaroun MS, Dillavou ED, Wheatley GH, Cambria RP. Five-year results of endovascular treatment with the Gore TAG device compared with open repair of thoracic aortic aneurysms. J Vasc Surg. 2008;47:912–8.CrossRefGoogle Scholar
  57. 57.
    Baumgartner H, Bonhoeffer P, De Groot NM, de Haan F, Deanfield JE, Galie N, et al. ESC guidelines for the management of grown-up congenital heart disease (new version 2010). Eur Heart J. 2010;31:2915–57.CrossRefGoogle Scholar
  58. 58.
    Bissell MM, Hess AT, Biasiolli L, Glaze SJ, Loudon M, Pitcher A, et al. Aortic dilation in bicuspid aortic valve disease: flow pattern is a major contributor and differs with valve fusion type. Circ Cardiovasc Imaging. 2013;6:499–507.CrossRefGoogle Scholar
  59. 59.
    Carr JA. The results of catheter-based therapy compared with surgical repair of adult aortic coarctation. J Am Coll Cardiol. 2006;47:1101–7.CrossRefGoogle Scholar
  60. 60.
    Gibbs JL. Treatment options for coarctation of the aorta. Heart. 2000;84:11–3.CrossRefGoogle Scholar
  61. 61.
    Mullen MJ. Coarctation of the aorta in adults: do we need surgeons? Heart. 2003;89:3–5.CrossRefGoogle Scholar
  62. 62.
    Ovaert C, McCrindle BW, Nykanen D, et al. Balloon angioplasty of native coarctation: clinical outcomes and predictors of success. J Am Coll Cardiol. 2000;35:988–96.CrossRefGoogle Scholar
  63. 63.
    Paddon AJ, Nicholson AA, Ettles DF, et al. Long-term follow-up of percutaneous balloon angioplasty in adult aortic coarctation. Cardiovasc Intervent Radiol. 2000;23:364–7.CrossRefGoogle Scholar
  64. 64.
    Varma C, Benson LN, Butany J, et al. Aortic dissection after stent dilatation for coarctation of the aorta: a case report and literature review. Catheter Cardiovasc Interv. 2003;59:528–35.CrossRefGoogle Scholar
  65. 65.
    Bell RE, Taylor PR, Aukett M, et al. Endoluminal repair of aneurysms associated with coarctation. Ann Thorac Surg. 2003;75:530–3.CrossRefGoogle Scholar
  66. 66.
    Ince H, Petzsch M, Rehders T, et al. Percutaneous endovascular repair of aneurysm after previous coarctation surgery. Circulation. 2003;108:2967–70.CrossRefGoogle Scholar
  67. 67.
    De Paepe A, Devereux RB, Dietz HC, Hennekam RC, Pyeritz RE. Revised diagnostic criteria for the Marfan syndrome. Am J Med Genet. 1996;62:417–26.CrossRefGoogle Scholar
  68. 68.
    Collod G, et al. A second locus for Marfan syndrome maps to chromosome 3p24.2-p25. Nat Genet. 1994;8:264–8.CrossRefGoogle Scholar
  69. 69.
    Milewicz DM, Pyeritz RE, Crawford S, Byers PH. Marfan syndrome: defective synthesis, secretion, and extracellular matrix formation of fibrillin by cultured dermal fibroblasts. J Clin Invest. 1992;89:79–86.CrossRefGoogle Scholar
  70. 70.
    Kallenbach K, Baraki H, Khaladj N, Kamiya H, Hagl C, Haverich A, Karck M. Aortic valve-sparing operation in Marfan syndrome: what do we know after a decade? Ann Thorac Surg. 2007;83:S764–8.CrossRefGoogle Scholar
  71. 71.
    Treasure T, Takkenberg JJ, Golesworthy T, Rega F, Petrou M, Rosendahl U, et al. Personalised external aortic root support (PEARS) in Marfan syndrome: analysis of 1-9 year outcomes by intention-to-treat in a cohort of the first 30 consecutive patients to receive a novel tissue and valve-conserving procedure, compared with the published results of aortic root replacement. Heart. 2014;100:969–75.CrossRefGoogle Scholar
  72. 72.
    Singh SD, Xu XY, Pepper J, Izgi C, Treasure T, Mohiaddin RH. Effects of aortic root motion on wall stress in the Marfan aorta before and after personalised aortic root support (PEARS) surgery. J Biomech. 2016;49:2076–84.CrossRefGoogle Scholar
  73. 73.
    Germain DP. Ehlers-Danlos syndrome type IV. Orphanet J Rare Dis. 2007;2:32.CrossRefGoogle Scholar
  74. 74.
    Loeys BL, Schwarze U, Holm T, Callewaert BL, Thomas GH, Pannu H, et al. Aneurysm syndromes caused by mutations in the TGF-beta receptor. N Engl J Med. 2006;355:788–98.CrossRefGoogle Scholar
  75. 75.
    Cooper DG, Walsh SR, Sadat U, Hayes PD, Boyle JR. Treating the thoracic aorta in Marfan syndrome: surgery or TEVAR? J Endovasc Ther. 2009;16:60–70.CrossRefGoogle Scholar
  76. 76.
    Ince H, Rehders TC, Petzsch M, Kische S, Nienaber CA. Stent-grafts in patients with Marfan syndrome. J Endovasc Ther. 2005;12:82–8.CrossRefGoogle Scholar
  77. 77.
    Adams JD, Kern JA. Blunt thoracic aortic injury: current issues and endovascular treatment paradigms. Endovasc Today. 2014;13:38–42.Google Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Cardiology and Aortic Centre, Royal Brompton & Harefield NHS Trust and Cardiovascular DepartmentNational Heart and Lung Institute, Faculty of Medicine, Imperial College LondonLondonUK

Personalised recommendations