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Ann Thorac Surg 2005;80:1478
© 2005 The Society of Thoracic Surgeons
Cardiovascular Surgery, University of Siena, Cardiovascular Surgery DPT, Siena University, Hospital Viale M. Bracci 1, Siena, Italy53100
(Email: nerie{at}unisi.it).
The treatment of thoracic aneurysms (TAAs) still poses a major challenge to the cardiothoracic surgeon. Thanks to the pioneering work of Dake and colleagues [1] in Stanford, Buffolo and colleagues [2] in Sao Paulo and others [3] who pioneered stent-graft repair of TAAs, endovascular technology now represents a true alternative to open surgery in selected patients.
The excellence of these results is highlighted in that an endovascular option is now offered to many patients, usually the elderly, who have presented serious co-morbidities or absolute contraindications to surgery. Thoracic stent grafts are now used with confidence in the management of a wide variety of thoracic aortic pathologies, including acute and chronic dissection, intramural hematoma, penetrating ulcer, traumatic injuries, and other diseases.
Vascular stent technology is advancing quickly; nonetheless many of the technical challenges are specifically associated with the need to maintain flow to vital arteries while excluding the aneurysm from the circulation. As we all realize, these difficulties are still not resolved with branched grafts.
The Berne group reports the results of a procedure (ie, supra aortic trunk focalization and arch stent grafting), which at the moment is the only practical endovascular alternative to aortic arch replacement. An addition to the excellent results in a high-risk population, this series is important because it is the largest study of a hybrid, less invasive, approach to transverse arch aneurysms. This study comes after many isolated case reports and ratifies the passage of this procedure to critical clinical evaluation. The methodology used in this series is pioneering.
The results of prospective controlled trials that compare outcomes of stent-graft therapy with those of surgery in patients with specific types of aortic disease are anxiously being awaited. However, we may reasonably doubt whether these results will soon be available or whether they will be universally accepted. There are two main reasons for this. The first reason is that only a few centers have expertise in open thoracic aortic arch (TAA) surgery; therefore, their results may not be applicable outside their walls. The other reason is that with the advent of endovascular therapy, TAA and other thoracic aortic diseases may not remain a surgical prerogative because treatment increasingly depends upon the specialty of the physician who recruits the patient.
In hybrid procedures that require both surgical and endovascular skills, surgeons necessarily have a primary role, and this is the best situation for the design of robust randomized studies.
We now have the opportunity to confirm the potential generated by this initial experience (ie, supra aortic trunk focalization and arch stent grafting is safe in high-risk patients). However, safer is only half the answer. Is the new procedure better, more effective, and durable?
Carrel and colleagues [4] bequeathed to us the privilege of answering the second half of the question.
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