Ann Thorac Surg 2006;82:572
© 2006 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Martin Czerny, MD
Department of Cardiothoracic Surgery, University of Vienna, Waeringer Guertel 18-20, Vienna, 1090 Austria
(Email: bypass{at}eunet.at).
The authors [1] report their experience with 18 patients who had extended applications of endovascular stent-graft placement of the thoracic aorta. This is a valuable clinical report with a high success rate. I would like to comment on some issues that may improve the understanding and thereby the prevention of some pitfalls of this new technique in these distinct anatomical regions.
As the authors have experienced, rate of endoleak formation, especially type I endoleaks within the aortic arch show a higher frequency than in straight segments, such as the descending aorta. The only possibility of overcoming this problem to date is to aggressively extend landing zones by liberal application of supra-aortic rerouting techniques, either autologous or alloplastic. Furthermore, one should not underestimate the importance of the left subclavian artery, not because of critical perfusion of the upper extremity; normally this does not pose any substantial problem, except with regard to posterior brain circulation and as a source of late type II endoleak formation through retrograde perfusion of the aneurysmal sac.
In regard to the distal landing zone, things are more complex, as visceral rerouting procedures are challenging for both surgeons and patients, and they are not comparable with supra-aortic reroutings in regard to their invasiveness. It remains to be shown, especially in the visceral segment, if branched stent-grafts will have their validity of a claim in the future.
We are aware that endovascular stent-graft placement in some patients, especially in the critically ill, is more a palliation than a definite solution, and that remaining or newly developing endoleaks are the price to pay instead of leaving a heavily diseased aortic segment untreated. However, extensive application of rerouting procedures, as the authors have effectively shown in their report may substantially add in treating patients with acute and chronic diseases of the aorta in delicate anatomic regions not suitable for any kind of conventional repair.
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- Dagenais F, Shetty R, Normand J-P, Turcotte R, Mathieu P, Voisine P. Extended applications of thoracic aortic stent grafts Ann Thorac Surg 2006;82:567-572.[Abstract/Free Full Text]
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