Endovascular Repair of Thoracic Aortic Aneurysm

What is thoracic endovascular aortic repair (TEVAR)?

Thoracic endovascular aortic repair (TEVAR) is a minimally invasive procedure that repairs damage to your aorta in your chest.

Your aorta is the largest artery in your body. It has many branches that supply blood to all of your organs and tissues. Many things can go wrong with your aorta, including an aneurysm (abnormal bulge in a weak area of your artery wall) or a tear in the lining of the walls (dissection). Healthcare providers commonly use TEVAR to treat aortic aneurysms and dissections in the descending thoracic aorta. Without treatment, these aneurysms and dissections can be deadly.

In years past, surgeons used open surgery to treat thoracic aortic aneurysms and dissections. But they now prefer TEVAR in many cases. That’s because TEVAR has an easier recovery and a lower risk of serious complications in appropriate candidates. Your provider will decide if you’re a candidate based on the anatomy of your blood vessels and other factors.

What does TEVAR treat?

Surgeons use TEVAR to repair aortic damage due to:

• Thoracic aortic aneurysms in the descending aorta. This is the part of your aorta that curves downward through your chest and into your belly (abdomen).
• Aortic dissection.
• Aortic transection (tears or damage from car accidents and other traumatic causes of severe damage to your chest).

How should I prepare for a TEVAR procedure?

Your healthcare provider will tell you how you should prepare. You may need to:

• Take medications to manage blood pressure and/or cholesterol levels.
• Stop smoking or using other tobacco products.
• Make changes to your usual medication schedule.
• Have preoperative testing (explained further below).

Preoperative testing

Your provider may order tests to help plan your procedure. A common test you can expect is a computed tomography (CT) angiogram. A CT angiogram can show the size and health of the arteries your provider will need to access during TEVAR.

For TEVAR to succeed, you need to have enough room in your arteries for the catheter to reach your aorta. Providers typically guide the catheter through your femoral artery (in your upper thigh) or iliac artery (in your pelvis). If these arteries are narrowed from plaque or otherwise unusable, your provider will need to find an alternative approach.

Imaging tests also help your provider choose the proper size and type of stent graft. The stent graft helps reline your artery to cover the tear in the artery in the case of a dissection or transection. For an aneurysm, the stent graft helps seal off the enlarged portion of the artery from flow to remove the risk of growing or rupturing.

Stent graft selection

Providers choose the size and type of stent graft that best suits your needs. For example, providers use a fenestrated stent graft to treat more complex aneurysms. A fenestrated stent graft has holes that allow blood to flow into arteries branching from your aorta. Such devices might be necessary for aneurysms that:

• Involve your aortic arch (the curved part at the top of your aorta that connects the ascending and descending segments).
• Extend through your chest and belly (thoracoabdominal aneurysms).
• Involve arteries branching from your aorta that lead to your intestines, brain or arms.

Your provider can tell you more about the type of device that’s best for you and why.

What happens during a TEVAR procedure?

To perform TEVAR, your surgical care team will:

1. Give you general anesthesia or local anesthesia along with a sedative to keep you comfortable during the procedure.
2. Take measures to lower the risk of damage to your spine (a possible complication of TEVAR). One method involves placing a lumbar (spinal) drain. This is a tube that drains cerebrospinal fluid during the procedure. Providers determine which measures are necessary on a case-by-case basis.
3. Make a small incision in the skin near your femoral artery (in your groin) to access your arteries.
4. Thread a guide wire through your arteries until it’s beyond the damaged area.
5. Use fluoroscopy guidance to insert a catheter over the guide wire. The catheter holds a stent graft and makes it easier to deliver the stent graft through your blood vessels.
6. Guide the stent graft to the damaged area.
7. Withdraw the catheter, leaving the stent graft in place. The stent graft then expands like a spring to fit against the walls of your aorta. It acts as a new lining for your aorta, preventing blood from pushing against the weakened areas of your aorta’s walls.
8. Stitch and cover the incision site in your groin with a bandage.

Hybrid approaches

Providers sometimes use hybrid approaches for aneurysms that affect a large portion of your aorta. This means they use endovascular techniques, as well as open surgery. Your provider can tell you more about these options for aorta surgery if they’re relevant to you.

How long does TEVAR surgery take?

TEVAR typically takes about two hours.

In TEVAR, a catheter delivers a stent-graft to the site of your aneurysm. It serves as a new lining for your aorta.

What happens after this procedure?

You may need to stay in the intensive care unit (ICU) for one or two days after your procedure. This will depend on the area being treated. Your care team will keep a close eye on you and watch for signs of complications. You’ll then move to a regular hospital room for continued monitoring. You can expect to go home within one day to one week.

What are the benefits of TEVAR?

Healthcare providers typically prefer TEVAR over open surgery because TEVAR:

• Has equal success to open surgery in fixing the problem.
• Has a quicker and easier recovery, including less time in the hospital.
• Has a lower risk of serious complications or death.
• Doesn’t require a thoracotomy (open chest incision).
• Leads to less blood loss and pain.
• Has a lower risk of organ damage from lack of blood flow (end-organ ischemia).

How successful is this procedure?

TEVAR has a higher survival rate than open surgery. About 98% of people survive the TEVAR procedure, while about 88% to 94% survive open surgery. Aorta centers that specialize in treating aortic disease have the best outcomes.

What are the risks or complications of TEVAR?

All procedures come with some level of risk. Possible risks of TEVAR include:

• Endoleak.
• Infection.
• Movement of the graft.
• Leg paralysis (paraplegia) from lack of blood flow to your spine (spinal ischemia).
• Heart attack.
• Stroke.

Talk to your provider about the risks of this procedure and what they can do to lower them.

What is the recovery time?

You’ll likely go home from the hospital within a day to a week of your procedure. Follow your provider’s guidance on when you can resume normal activities. In general, you may need to:

• Wait one to two weeks to drive.
• Avoid baths until your groin incisions heal (showers and sponge baths are OK).
• Avoid lifting more than 10 pounds for one to two weeks.

Your provider may also recommend lifestyle changes. These include following a heart-healthy diet and getting more exercise.

Follow-up appointments

Follow-ups are crucial and lifelong after any aorta surgery, including TEVAR. You can expect to see your provider for imaging tests:

• One month after your procedure.
• Six months after your procedure (if your provider notices concerns at one month).
• Twelve months after your procedure.
• Annually after that.

The imaging tests will show if the graft is still in the proper place and if there are endoleaks or other complications. Your provider will recommend appropriate treatment if complications arise.

When should I call my healthcare provider?

Call your provider if you have questions or concerns about your treatment plan or recovery. They’re available to answer your questions and help you feel comfortable with the process.

When to go to the ER

Call 911 or your local emergency number if you have symptoms of a heart attack or stroke. These are life-threatening medical emergencies that require immediate care.

Is TEVAR open-heart surgery?

No. TEVAR isn’t open-heart surgery. TEVAR is an endovascular procedure. That means it’s performed from the inside of your aorta using thin, long tubes called catheters and is like relining the artery from the inside.

Your surgeon makes a small incision in your skin to access one of your arteries (usually the femoral artery in your upper thigh). They use a catheter to guide a stent graft through your arteries and deliver it to the damaged area. A stent graft is a fabric tube supported by metal mesh, and it “relines” your aorta. When you have an aneurysm, placing this new lining diverts blood flow away from the weak artery walls and relieves pressure on them. This lowers your risk of complications like aneurysm rupture or aortic dissection.