Treatment of Thoracic Aortic Diseases Petri Saari Endovascular Treatment of Thoracic Aortic Diseases

Thoracic aortic aneurysms and dissections can lead to devastating complications and eventually to premature death. A diseased segment of the aorta has traditionally been replaced with a surgical prosthesis. Open surgery is, unfortunately, associated with relatively high mortality and morbidity. Stent graft treatment was introduced on the side of open surgery 20 years ago, and there have been high hopes that mortality and morbidity could be lowered with this kind of mini-invasive procedure. Experiences have been promising, and patients tend to survive better after stent graft treatment, at least in the short term. However, the long-term durability of the first-generation stent grafts was not sufficient, which led to unnecessary reoperations and even ruptures of the treated segments. Stent design has been improved since, but the survival benefit of the stent graft– treated patients seems to vanish in 5 years. To be successful, stent graft treatment must overcome some limitations: Stent grafts need adequate landing zones in both ends of the graft, and important side branches of the aorta cannot be covered without consequences. The latest in stent graft design is the fenestrated graft, which was developed to overcome these obstacles. These grafts are very expensive, however, and because they have to be tailored individually to each patient, cannot be used in acute situations. Intraoperative fenestration of the stent graft may be a way to make this treatment more available. Stent graft fabrics are quite difficult to traverse, though, and the dilatation of the fenestration is greatly facilitated when a cutting balloon is used. Nevertheless, the device to be used in the creation of fenestration needs some improvements. Endovascular treatment of a thoracic aortic aneurysm is relatively safe, at least in the elective setting. However, to reduce the risk of periprocedural and postoperative complications, multidisciplinary and detailed preoperative imaging-based planning is helpful. A rigorous postoperative surveillance program is still compulsory for early detection and prompt treatment of late type I or III endoleak and to reduce the risk of late ruptures. Marfan syndrome and especially Loeys–Dietz syndrome are debilitating connective tissue disorders, and these patients are very prone to developing vascular complications, particularly of the aorta. The nature of these diseases mandates aggressive treatment strategies and close surveillance programs. Open surgery remains the mainstay of the treatment, but endovascular options should be considered whenever possible to reduce operative complications. Endovascular treatment should be planned so that the landing zones lie within the previously treated aorta. National Library of Medicine Classification: