Endovascular repair of thoracic aortic aneurysm

Overview

Thoracic endovascular aortic repair (TEVAR) is a less invasive procedure designed to address issues in the aorta located within the chest. The aorta, the body’s largest artery, plays a crucial role in supplying blood to various organs and tissues. The aorta can develop problems such as an aneurysm (an abnormal bulging in a weak section of the artery wall) or a tear in its inner lining (dissection). TEVAR is a commonly used method for treating aortic aneurysms and dissections occurring in the descending thoracic aorta. Left untreated, these conditions can be life-threatening.

In the past, surgeons typically relied on open surgery to manage thoracic aortic aneurysms and dissections. However, TEVAR has become the preferred approach in many cases due to its advantages, including a smoother recovery process and a lower risk of serious complications, provided the patient’s anatomy and other relevant factors make them a suitable candidate. Your healthcare provider will evaluate your candidacy based on your vascular anatomy and other relevant factors.

Reasons for undergoing this procedure

Surgeons employ TEVAR (thoracic endovascular aortic repair) to address aortic injuries stemming from the following conditions:

• Aortic dissection, a condition characterized by the separation of the layers of the aortic wall.
• Thoracic aortic aneurysms located in the descending aorta, which is the section of the aorta that bends downward through the chest and extends into the abdomen.
• Aortic transection, which involves tears or damage to the aorta resulting from traumatic events such as car accidents and other severe chest injuries.

Risks

Healthcare providers generally favor TEVAR (thoracic endovascular aortic repair) over open surgery for several reasons:

• TEVAR offers comparable success rates to open surgery in addressing the medical issue.
• Facilitates a faster and smoother recovery, often resulting in reduced hospitalization duration.
• TEVAR carries a lower risk of severe complications or mortality compared to open surgery.
• It eliminates the need for a thoracotomy, which involves making an open chest incision.
• TEVAR results in reduced blood loss and less post-operative pain.
• There is a decreased risk of organ damage due to inadequate blood flow, known as end-organ ischemia.

Before the procedure

To prepare for TEVAR, follow these steps as advised by your healthcare provider:

• Manage medications: Adjust any drugs you’re taking for blood pressure or cholesterol.
• Stop tobacco use: Quit smoking or using tobacco products.
• Review current medications: Change your usual medication schedule if necessary.

Preoperative Testing

• Computed tomography angiogram (CTA): This test checks your arteries’ size and health to ensure the catheter can reach your aorta, typically via the femoral or iliac artery. If these are too narrow, an alternative route is needed.

Stent Graft Selection

When selecting a stent graft for your procedure, healthcare providers determine the most suitable size and type based on your individual needs. Complex aneurysms often require a fenestrated stent graft, which is equipped with openings to ensure blood continues to flow to the arteries branching off from the aorta. This type of stent graft is particularly beneficial for aneurysms affecting the aortic arch, those that span the chest and abdominal area (thoracoabdominal aneurysms), or aneurysms impacting branches that supply blood to the intestines, brain, or arms. Your healthcare provider will provide detailed information on the best stent graft for your situation and the reasoning behind this choice.

During the procedure

To perform a TEVAR, the clinical team will proceed as follows:

• Administer anesthetic agents—either general or regional—accompanied by a sedative to maintain patient comfort throughout the operation.
• Implement prophylactic measures to reduce the risk of spinal injury, one of which may include the placement of a lumbar drain for cerebrospinal fluid diversion, adjudicated on an individual basis.
• Perform a precise incision adjacent to the femoral artery in the inguinal region to establish arterial access.
• Introduce and advance a guide wire through the arterial system, traversing the area of pathology.
• Utilize fluoroscopic guidance to facilitate the insertion of a catheter over the guide wire, which conveys a stent graft intended for deployment within the vasculature.
• Navigate the stent graft to the lesion site.
• Remove the catheter, which allows the stent graft to deploy and affix to the aortic walls, serving as an internal support and reducing the pressure on the weakened sections of the aorta.
• Approximate the incisional aperture and apply a sterile dressing upon completion.

The TEVAR procedure is generally completed within an approximate timeframe of two hours.

Hybrid approaches

For aneurysms involving extensive areas of the aorta, clinicians may employ a combination of methods, integrating endovascular procedures with traditional open surgical techniques. Your healthcare provider can offer detailed insights into these surgical options should they be pertinent to your case.

After the procedure

Post-procedure, you may require a one to two-day stay in the intensive care unit (ICU), contingent upon the specific region treated. During this period, your medical team will closely monitor you for any indications of complications before transferring you to a standard hospital ward for ongoing observation. Typically, you’ll be discharged and able to return home within a span ranging from one day to a week.

Outcome

After your procedure, you’ll typically be discharged from the hospital within a week. It’s important to adhere to your healthcare provider’s advice about resuming your usual activities. Generally, you should:

• Postpone driving for one to two weeks.
• Refrain from taking baths until the incisions in your groin are fully healed (you can take showers or sponge baths).
• Avoid lifting anything heavier than 10 pounds for the first one to two weeks.

Your healthcare provider may also suggest making changes to your lifestyle, such as adopting a diet beneficial for heart health and incorporating more physical activity into your daily routine.

Regular follow-up appointments are essential and ongoing after any aortic surgery, including TEVAR. You will likely need to schedule imaging tests with your provider:

• One month following your surgery.
• Six months post-surgery, especially if there were concerns at the one-month check-up.
• At the one-year mark post-surgery.
• Yearly thereafter.

These imaging tests are crucial for monitoring the position of the graft and detecting any endoleaks or other issues. Should any complications be identified, your provider will discuss further treatment options with you.

If you have any questions or concerns about your recovery or treatment plan, don’t hesitate to reach out to your healthcare provider. They are there to provide support and ensure you are comfortable throughout your recovery process.