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Endoluminal repair is now a realistic alternative to open surgery for the treatment of thoracic aortic disease
Since Volodos and colleagues performed the first endoluminal repair of a thoracic aneurysm, the technique has been used to treat descending thoracic aneurysms, type B (Stanford) aortic dissection, false aneurysms, penetrating ulcers, and aortic transection.1,2 This minimally invasive approach has many advantages over conventional surgery as it avoids open thoracotomy, single lung ventilation, and aortic cross clamping.
The main criticism of endoluminal repair is poor durability of the stent grafts. The first published series from Stanford used home made stent grafts and reported a primary success rate of 73%.3 However, there were problems associated with the large introducer catheters and rigidity of these devices. The now commercially available stent grafts are more flexible with smaller delivery systems and have improved deployment mechanisms. Notably, stent graft failure has been reported with the early home made grafts and more recently the Gore Excluder (WL Gore Associates, Inc, Flagstaff, Arizona, USA) has been withdrawn for redesigning following reports of fractures in the nitinol frame. The longer experience from the infrarenal devices has shown that lifelong surveillance is essential.
INDICATIONS FOR TREATMENT
Descending thoracic aneurysms are life threatening, with an estimated incidence of 6 cases per 100 000 person years.4 The number of patients with thoracic aneurysms is increasing presumably because of better diagnostic modalities and longer life expectancy.5 We advise treatment for symptomatic aneurysms and for asymptomatic aneurysms greater than 6 cm in diameter. Several reports have reported the risk of rupture in patients with untreated aneurysms to range from 46–74%, with five year survival rates estimated at 9–13%.4 The contraindications for endovascular repair of thoracic aneurysms are absence of an aneurysm neck, an excessively large neck, or insufficient normal …
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