Endovascular Repair of Thoracic Aortic Aneurysms
A thoracic aortic aneurysm, an abnormal bulge in a weakened wall of the aorta in the chest area, can cause a variety of symptoms and often life-threatening complications. Due to the serious risks it presents, timely diagnosis and treatment of a thoracic aneurysm are critical.
The standard surgical treatment for thoracic aortic aneurysms is open-chest aneurysm repair, but Cleveland Clinic surgeons are now able to treat many thoracic and thoracoabdominal (occurring in the lower part of the thoracic aorta and the upper part of the abdominal aorta) aneurysms with a minimally invasive procedure called an endovascular stent graft.
What is an endovascular stent graft?
Endovascular means that surgery is performed inside your aorta using thin, long tubes called catheters. Through small incisions in the groin, the catheters are used to guide and deliver a stent-graft through the blood vessels to the site of the aneurysm. The stent graft is then deployed in the diseased segment of the aorta and "relines" the aorta like a sleeve to divert blood flow away from the aneurysm.
An endovascular stent graft is a fabric tube supported by metal wire stents (also called a scaffold) that reinforces the weak spot in the aorta. By sealing the area tightly with your artery above and below the aortic aneurysm, the graft allows blood to pass through it without pushing on the aneurysm.
What are the benefits of endovascular repair?
Endovascular repair of thoracic aneurysms is generally less painful and has a lower risk of complications than traditional surgery because the incisions are smaller. Endovascular aorta aneurysm procedures also allow you to leave the hospital sooner and recover more quickly after your aorta repair.
Who is a candidate for endovascular repair of a thoracic aneurysm?
You may be eligible for endovascular stent grafting if your thoracic aneurysm has not ruptured and the aneurysm is 5 centimeters or more in size.
Your physician can determine if aortic aneurysm repair is the best treatment by performing one or a combination of imaging studies, which may include:
- High resolution, computed tomography (CT) scan
- Magnetic resonance imaging (MRI)
- Angiography (an x-ray of the blood vessels)
- Transesophageal echocardiography (TEE), to record ultrasound images of your heart from inside your esophagus, or food pipe
- Intravascular ultrasound
Physical characteristics of the aorta and the aortic aneurysm itself are very important in determining if endovascular aorta repair is the best treatment.
What happens during endovascular stent grafting?
Your surgeon will make small incisions in the skin above the femoral artery (the large artery that supplies blood to each leg) in the groin. A guide wire is threaded through the artery beyond the area of the thoracic aneurysm.
By using x-ray guidance, your surgeon inserts the device over the guide wire. The stent-graft device is constrained within a catheter to make it easier to deliver the stent-graft through your blood vessels. Once the graft is guided to the thoracic aneurysm site, the catheter is withdrawn, exposing the stent-graft in place. The stent-graft then expands like a spring to fit against the walls of the aorta on either side of the aneurysm, and delivers blood flow through the weakened section.
Once the stent-graft is in place, the blood flows through the graft, avoiding the aneurysm. Over time, the aneurysm typically shrinks due to the blood pressure being diverted away from the aneurysm.
CT showing a thoracic aortic aneurysm before surgery:
red arrow: left subclavian artery
yellow arrow: left common carotid artery
green arrow: proximal extent of thoracic aortic aneurysm
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thoracic aorta stented
red arrow: stent within the proximal subclavian artery
yellow: stent in left common carotid artery
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Cleveland Clinic surgeons are also using fenestrated and branched endografts to treat more complex thoracic aneurysms involving the aortic arch and thoracoabdominal aneurysms (those which involve the aorta both in the chest and the abdomen). Additionally, branched and fenestrated grafts are used to extend thoracic grafts to repair those aneurysms that involve the vessels leading to the intestines or the brain and arms.
Digital CT showing endovascular stenting of an abdominal aortic aneurysm with bilateral iliac aneurysms, using a techniques that preserves flow into both internal iliac arteries (purple arrows)
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For those patients with extensive aortic or multiple aneurysms, the best approach may require a combination of open surgery and endovascular repair. This combined therapy is referred to as a hybrid approach and most often includes what is known as an elephant trunk procedure.
What are the risks of endovascular repair of thoracic aneurysms?
Although endovascular surgery reduces recovery time to a few days, there are still potential risks. The possible complications of endovascular repair include:
- Leaking of blood around the graft, known as “endoleak”
- Movement, or migration, of the graft away from its initial placement
- Stent fracturing
Additional complications that are rare but serious include:
- Delayed rupture of the aneurysm
Your surgeon will discuss the benefits and potential risks of the procedure with you.
The long-term durability of endovascular stent grafting to treat a thoracic aneurysm is yet unknown because this is a fairly new procedure. For this reason, patients who have endovascular repair of their thoracic aneurysms must be monitored closely on a regular basis with examinations and imaging studies.
How long will it take to recover from endovascular repair of a thoracic aneurysm?
Your hospital stay following endovascular stent grafting is usually 2 to 3 days. While your recovery will take less time than recovering from open-chest thoracic aneurysm surgery, the early restrictions are similar and include:
- No driving until approved by your physician (usually within 1-2 weeks after the procedure, and no longer taking pain medication)
- No baths until the groin incisions heal; showers and sponge baths around the incision are permitted
- Avoid lifting more than 10 pounds for approximately 4 - 6 weeks after the procedure
You will return for a follow-up visit within one month of the procedure. Follow-up imaging tests will take place 1 and 6 months following the procedure to make certain the stent is still functioning and in the proper location. If you aneurysm is shrinking and no problems are found, your subsequent imaging tests will take place yearly.
After you’ve had an endovascular repair of an aneurysm, it is recommended you adopt the same heart-healthy lifestyle led by other heart surgery patients. Your health care team can provide more information.
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If you need more information or would like to make an appointment, call the Heart and Vascular Institute Resource Nurses at: 216/445-9288 or toll free at 866/289-6911, Monday through Friday from 8:30 am to 4:00 pm, Eastern Standard Time, or use the contact us form.
- Vascular Web, Society for Vascular Surgery. Endovascular Stent Graft. (Accessed 21 May, 2006)
- The Society of Thoracic Surgeons. Aortic Aneurysms.(2006). (Accessed 18 May, 2006)
- Vascular Web, Society for Vascular Surgery. Thoracic Aneurysm. (2006). (Accessed 18 May, 2006)
- Ouriel, K, Greenberg, RK. Endovascular Treatment of Thoracic Aortic Aneurysms. J Card Surg, 2003; 18:455-463.
- Greenberg RK, West K, Pfaff K, et al. Beyond the aortic bifurcation: branched endovascular grafts for thoracoabdominal and aortoiliac aneurysms. J Vasc Surg 2006 May; 43(5) :879-86; discussion 886-7.
- Greenberg, RK, O’Neill, S, Walker E, Haddad F, Lyden SP, Svensson LG, Lytle B, Clair DG, and Ouriel K. Endovascular repair of thoracic aortic lesions with the Zenith TX1 and TX2 thoracic grafts: Intermediate-term results. Journal of Vascular Surgery, April 2005; 41:589-596.
- O’Neill S, Greenberg RK, Resch T, Bathurst S, Fleming D, Kashyap V, Lyden SP, Clair D. An evaluation of centerline of low measurement techniques to assess migration after thoracic endovascular aneurysm repair. J Vasc Surg 2006 June; Vol. 43, Issue 6, 1103-1110.
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