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Aneurysms of the thoracic aorta: stent or surgery?

Diseases of the Aorta

Surgery, Stent grafts and Hybrid Procedures, a Strong Armamentarium to Improve Results for Treatment of Aortic Aneurysms

C. Nienaber pointed out that the incidence of thoracic aneurysms is increasing; this is followed by an increased rate of treatment and constantly decreasing rate of misdiagnoses. Increasing age in the total population and lifestyle appear to be important factors for the higher rate. Currently, still about 30% of acute thoracic syndromes are missed. The international registry on acute type A dissection revealed a mortality rate of 38% within the first 15 days, significantly less than former observations. Strict control of hypertension has been proven to improve long term results.

For type B dissections the peak incidence for male is 15/100 000 at an age between 65 and 74 years. However, for females it is 19 / 100 000 at 75 to 84 years. Stent therapy in acute type B dissection only showed a benefit in high risk situations, such as pleural effusions or wall hematomas.

Dr Grabenwoeger gave insights into the development on stentgraft techniques and hybrid procedures. Distal extension of an arch replacement with a stentgraft, the so called “frozen elephant” technique was able to reduce aortic complications after 5 years compared to the standard hemi-arch replacement (96 % freedom vs 73%).
For high risk patients, debranching or rerouting techniques are evolving. In cases without a proper landing zone for stentgrafts subclavian, left carotid or even the brachiocephalic trunk are transposed and the diseased aortic segment is treated with a stentgraft. In 61 high risk patients, mortality was 5% and only one neurologic complication occurred.
The results of the same approach in distal thoracic and thoraco-abdominal aneurysms are still confusing. Many series mix distal thoracic and thoraco-abdominal, others arch and thoraco-abdominal repair. Surgery vs stentgraft series mostly show superior results for surgery.

Dr Riambeu focused on the devastating complication of paraplegia. He formulated a new site of pathology away from the belief in the importance of a single Adamkiewicz artery towards a complex influence of collateral network, blood pressure, tolerance to ischemia, reperfusion and length of excluded segment.

Spinal fluid drainage and maintenance of a normal blood pressure appear the most potent measures for surgery as well as for stentgraft in critical segments and for extended lengths. Spinal pressure should be kept just below the individual pressure to avoid subdural hemorrhage.




Aneurysms of the thoracic aorta: stent or surgery?

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.