SOCIETY FOR VASCULAR SURGERY PRACTICE GUIDELINES

Society for Vascular Surgery clinical practice guidelines of thoracic

endovascular aortic repair for descending thoracic aortic aneurysms
Gilbert R. Upchurch Jr, MD,a Guillermo A. Escobar, MD,b Ali Azizzadeh, MD,c Adam W. Beck, MD,d
Mark F. Conrad, MD,e Jon S. Matsumura, MD,f Mohammad H. Murad, MD,g
R. Jason Perry, MD,h Michael J. Singh, MD,i Ravi K. Veeraswamy, MD,j and Grace J. Wang, MD,k Gainesville, Fla;
Atlanta, Ga; Los Angeles, Calif; Birmingham, Ala; Boston, Mass; Madison, Wisc; Rochester, Minn; Seattle, Wash; Pittsburgh
and Philadelphia, Pa; and Charleston, SC

ABSTRACT
Thoracic aortic diseases, including disease of the descending thoracic aorta (DTA), are significant causes of death in the
United States. Open repair of the DTA is a physiologically impactful operation with relatively high rates of mortality,
paraplegia, and renal failure. Thoracic endovascular aortic repair (TEVAR) has revolutionized treatment of the DTA and
has largely supplanted open repair because of lower morbidity and mortality. These Society for Vascular Surgery Practice
Guidelines are applicable to the use of TEVAR for descending thoracic aortic aneurysm (TAA) as well as for other rarer
pathologic processes of the DTA. Management of aortic dissections and traumatic injuries will be discussed in separate
Society for Vascular Surgery documents. In general, there is a lack of high-quality evidence across all TAA diseases,
highlighting the need for better comparative effectiveness research. Yet, large single-center experiences, administrative
databases, and meta-analyses have consistently reported beneficial effects of TEVAR over open repair, especially in the
setting of rupture. Many of the strongest recommendations from this guideline focus on imaging before, during, or after
TEVAR and include the following:
In patients considered at high risk for symptomatic TAA or acute aortic syndrome, we recommend urgent imaging,
usually computed tomography angiography (CTA) because of its speed and ease of use for preoperative planning. Level
of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate).
If TEVAR is being considered, we recommend fine-cut (#0.25 mm) CTA of the entire aorta as well as of the iliac and
femoral arteries. CTA of the head and neck is also needed to determine the anatomy of the vertebral arteries. Level of
recommendation: Grade 1 (Strong), Quality of Evidence: A (High).
We recommend routine use of three-dimensional centerline reconstruction software for accurate case planning and
execution in TEVAR. Level of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate).
We recommend contrast-enhanced computed tomography scanning at 1 month and 12 months after TEVAR and
then yearly for life, with consideration of more frequent imaging if an endoleak or other abnormality of concern is
detected at 1 month. Level of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate).
Finally, based on our review, in patients who could undergo either technique (within the criteria of the device’s in-
structions for use), we recommend TEVAR as the preferred approach to treat elective DTA aneurysms, given its reduced
morbidity and length of stay as well as short-term mortality. Level of recommendation: Grade 1 (Strong), Quality of Evi-
dence: A (High).
Given the benefits of TEVAR, treatment using a minimally invasive approach is largely based on anatomic eligibility
rather than on patient-specific factors, as is the case in open TAA repair. Thus, for isolated lesions of the DTA, TEVAR
should be the primary method of repair in both the elective and emergent setting based on improved short-term and
midterm mortality as well as decreased morbidity. (J Vasc Surg 2021;73:55S-83S.)

From the Division of Vascular Surgery, University of Florida, Gainesvillea; the Correspondence: Gilbert R. Upchurch Jr, MD, Department of Surgery, University
Division of Vascular Surgery, Emory University, Atlantab; the Division of of Florida, 1600 Archer Rd, Rm 6714, Gainesville, FL 32610 (e-mail: gib.
Vascular Surgery, Cedars-Sinai, Los Angelesc; the Division of Vascular Surgery, upchurch@surgery.ufl.edu).
University of Alabama at Birmingham, Birminghamd; the Division of Vascular Independent peer review and oversight have been provided by members of
Surgery, Massachusetts General Hospital, Bostone; the Division of Vascular the SVS Document Oversight Committee (Drs Thomas L. Forbes, Chair,
Surgery, University of Wisconsin, Madisonf; the Knowledge and Evaluation Ruth Bush, Vice-Chair, Neal Barshes, Keith Calligaro, Ronald L. Dalman,
Research Unit, Mayo Clinic, Rochesterg; the Department of Surgery, United Mark Davies, Yazan Duwayri, Alik Farber, Gregory Landry, Mahmoud Malas,
States Army, Seattleh; the Division of Vascular Surgery, University of Pitts- Katherine McGinigle, J. Sheppard Mondy, Marc Schermerhorn, and Cynthia
burgh Medical Center, Pittsburghi; the Division of Vascular Surgery, Medical Shortell).
University of South Carolina, Charlestonj; and the Division of Vascular Surgery, 0741-5214
University of Pennsylvania, Philadelphia.k Copyright Ó 2020 by the Society for Vascular Surgery. Published by Elsevier Inc.
Author conflict of interest: J.S.M. is a consultant and receives research grants https://doi.org/10.1016/j.jvs.2020.05.076
through the University of Wisconsin-Madison for Abbott, Cook, Gore, Med-
tronic, and Endologix. R.K.V. is a proctor and speaker for Cook and Medtronic.

55S
56S Upchurch et al Journal of Vascular Surgery
January Supplement 2021

TABLE OF CONTENTS Stroke .......................................................................................... 69S

Arm ischemia and vertebrobasilar
SUMMARY OF RECOMMENDATIONS ............................ 56S insufficiency ........................................................................... 70S
DEVELOPMENT OF GUIDELINES ..................................... 59S Additional considerations ........................................... 70S
DOCUMENT REVIEW AND APPROVAL ........................ 59S Renal protection strategies for TEVAR .................. 71S
METHODOLOGY AND EVIDENCE REVIEW ................. 59S Implementation remark ................................................... 72S
EPIDEMIOLOGY AND RISK FACTORS ........................... 60S Recommendation for coverage or occlusion of
Population affected .............................................................. 60S the CA during TEVAR .......................................................... 72S
Risk factors for disease and rupture ....................... 60S Recommendation for access during TEVAR .... 73S
Natural history and rupture rate of TAA .............. 60S Femoral access .................................................................... 73S
THE THORACIC AORTA: ANATOMY AND Iliac or aortic access ........................................................ 74S
CLASSIFICATIONS .................................................................... 60S Endoconduit .......................................................................... 74S
Anatomy of the thoracic aorta .................................... 60S Carotid-axillary access ................................................... 75S
Classifications of the zones and arch ..................... 61S Recommendations for treatment of
THORACIC AORTIC HISTOPATHOLOGY ....................... 61S symptomatic and ruptured TAAs ............................. 75S
Thoracic aneurysm and atherosclerotic SURVEILLANCE AFTER TEVAR ......................................... 75S
disease ............................................................................................. 61S Implementation remarks about surveillance .. 76S
Aortic vasculitides and inflammatory diseases 61S SPECIAL TAA CONSIDERATIONS .................................... 76S
PAU, IMH, and AD .................................................................. 62S CONCLUSIONS ........................................................................... 77S
Mycotic aneurysms and aortoesophageal and
aortobronchial fistulas ........................................................ 62S
SUMMARY OF RECOMMENDATIONS
Coarctation .................................................................................. 63S
Practice recommendations were made using the
Kommerell diverticulum .................................................. 63S
Tumors ............................................................................................ 63S Grading of Recommendations Assessment, Develop-
DIAGNOSTIC EVALUATION OF THORACIC AORTIC ment, and Evaluation (GRADE) system.1
DISEASE ........................................................................................ 63S Recommendation 1: In patients considered at low or in-
Values and preferences ..................................................... 63S termediate risk for a thoracic aortic aneurysm (TAA) based
History and physical examination in the on their history and physical examination findings, we sug-
evaluation of thoracic aortic disease ...................... 63S gest chest X-ray as the first radiographic test as it may iden-
History of the patient’s illness ................................. 63S tify an alternative diagnosis for symptoms and may obviate
Physical examination ..................................................... 64S the need for additional aortic imaging. Level of recom-
Diagnostic studies and imaging in
mendation: Grade 2 (Weak), Quality of Evidence: C (Low)
symptomatic patients .................................................... 64S
Preoperative workup in patients undergoing Recommendation 2: In patients considered at high risk
open surgical and endovascular repair ................ 64S for symptomatic TAA or acute aortic syndrome, we
Emergent or urgent repair ........................................ 64S recommend urgent imaging, usually computed tomog-
Elective repair ....................................................................... 64S raphy angiography (CTA) because of its speed and ease
Assessment of left ventricular function ................ 64S of use for preoperative planning. Magnetic resonance
Additional testing ................................................................... 64S angiography and transesophageal echocardiography
RECOMMENDATIONS FOR IMAGING OF THE DTA are also adequate for screening to identify thoracic aortic
BEFORE TEVAR ........................................................................ 65S disease but have limited applicability in certain scenarios
Chest radiography ................................................................. 65S (discussed further later). Level of recommendation:
CTA ..................................................................................................... 65S
Grade 1 (Strong), Quality of Evidence: B (Moderate)
MRA ................................................................................................... 65S
Intravascular ultrasound (IVUS) ................................... 66S Recommendation 3: For elective thoracic endovascular
PERIOPERATIVE MANAGEMENT AND OPERATIVE aortic repair (TEVAR) cases, we suggest assessment of left
DECISION-MAKING ................................................................. 66S ventricular function by transthoracic echocardiography
Perioperative medical management ..................... 66S in a patient with dyspnea of unknown origin or in a pa-
Open repair vs TEVAR for TAA ..................................... 66S tient with known congestive heart failure with worsening
Indications for repair ............................................................ 67S dyspnea. Level of recommendation: Grade 2 (Weak),
TEVAR for TAA ..................................................................... 67S Quality of Evidence: C (Low)
TEVAR for IMH and PAU ............................................. 67S Recommendation 4: If TEVAR is being considered, we
TEVAR for infected TAAs ............................................. 68S
recommend fine-cut (#0.25 mm) CTA of the entire aorta
Choice of anesthetic and monitoring
as well as of the iliac and femoral arteries. CTA of the
techniques ................................................................................... 68S
Anesthesia ............................................................................... 68S head and neck is also needed to determine the anatomy
Spinal cord protection .................................................. 68S of the vertebral arteries. Level of recommendation:
Management of the LSA and vertebrobasilar Grade 1 (Strong), Quality of Evidence: A (High)
system .............................................................................................. 69S Recommendation 5: We recommend routine use of
Spinal cord ischemia ...................................................... 69S three-dimensional centerline reconstruction software
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for accurate case planning and execution in TEVAR. Recommendation 14: We recommend TEVAR in pa-
Level of recommendation: Grade 1 (Strong), Quality of tients with IMH or penetrating aortic ulcer who have
Evidence: B (Moderate) persistent symptoms or complications or show evidence
Recommendation 6: We suggest contrast-enhanced of disease progression on follow-up imaging after a
magnetic resonance angiography for preoperative plan- period of hypertension control. Level of recommenda-
ning for patients with severe allergy to iodinated contrast tion: Grade 1 (Strong), Quality of Evidence: B (Moderate)
material. Level of recommendation: Grade 2 (Weak), Recommendation 15: We suggest TEVAR in selected
Quality of Evidence: C (Low) cases of asymptomatic penetrating aortic ulcer in pa-
Recommendation 7: We recommend intravascular ul- tients who have at-risk characteristics for growth or
trasound use in TEVAR for TAA to assess landing zones rupture. Level of recommendation: Grade 2 (Weak),
when cross-sectional imaging is of poor quality, a more Quality of Evidence: B (Moderate)
detailed evaluation of landing zones or branch vessel or- Recommendation 16: We suggest TEVAR for symptom-
igins is needed, or a decrease in contrast material use is atic mycotic/infected TAA as a temporizing measure, but
desired. Level of recommendation: Grade 1 (Strong), data demonstrating long-term benefit are lacking. Level
Quality of Evidence: B (Moderate) of recommendation: Grade 2 (Weak), Quality of Evi-
Recommendation 8: As hypertension is a modifiable risk dence: C (Low)
factor for the development of aortic aneurysms and is asso- Recommendation 17: We recommend increasing
ciated with accelerated aortic growth and rupture, we perfusion pressure through controlled hypertension
recommend that blood pressure be managed to the (mean arterial pressure >90 mm Hg) as a component
adherence of the American College of Cardiology/Amer- of a spinal cord protection protocol in patients at high
ican Heart Association guidelines.2 Level of recommenda- risk of spinal cord injury because of extensive coverage
tion: Grade 1 (Strong), Quality of Evidence: B (Moderate) length (>15 cm), poor hypogastric perfusion (occluded
Recommendation 9: We recommend interventions for or significantly stenosed hypogastric arteries), or
smoking cessation in patients with thoracic aortic dis- coverage of important collaterals (subclavian/hypogastric
ease as even passive exposure may increase the risk of arteries). Level of recommendation: Grade 1 (Strong),
aortic rupture. Level of recommendation: Grade 1 Quality of Evidence: B (Moderate)
(Strong), Quality of Evidence: A (High) Recommendation 18: We recommend prophylactic ce-
Recommendation 10: In patients who could undergo rebrospinal fluid drainage for spinal cord injury protec-
either technique (within the criteria of the device’s in- tion in TEVAR cases that are deemed high risk
structions for use), we recommend TEVAR as the (covering extensive length of descending aorta; previous
preferred approach to treat elective descending thoracic aortic coverage, including endovascular aneurysm repair
aorta (DTA) aneurysms, given its reduced morbidity and and open abdominal aortic aneurysm repair; compro-
length of stay as well as short-term mortality. Level of mised pelvic perfusion with diseased or occluded com-
recommendation: Grade 1 (Strong), Quality of Evi- mon or internal iliac arteries; diseased or occluded
dence: A (High) vertebral arteries; planned left subclavian artery [LSA]
Recommendation 11: We recommend TEVAR in coverage; or deemed high risk by the operating surgeon).
asymptomatic patients with a descending TAA when Level of recommendation: Grade 1 (Strong), Quality of
the maximum aneurysm diameter exceeds 5.5 cm in Evidence: B (Moderate)
“low-risk” patients with favorable aortic anatomy. Level Recommendation 19: For elective TEVAR of a TAA
of recommendation: Grade 1 (Strong), Quality of Evi- where coverage of the LSA is necessary for adequate
dence: B (Moderate) stent graft seal, we suggest preoperative or concomitant
Recommendation 12: We suggest using higher aortic LSA revascularization. Level of recommendation: Grade
diameter thresholds for TEVAR in patients deemed to 1 (Strong), Quality of Evidence: B (Moderate)
have a particularly high risk of death, renal failure, or Recommendation 20: For patients in whom the anat-
paraplegia from the procedure, where the benefit of omy to be treated compromises perfusion to vital struc-
treatment is lower than the risk posed by the natural his- tures, we recommend LSA revascularization. Level of
tory of the TAA. Level of recommendation: Grade 2 recommendation: Grade 1 (Strong), Quality of
(Weak), Quality of Evidence: C (Low) Evidence: B (Moderate)
Recommendation 13: Because of the dynamic nature Examples of these circumstances include the following:
of isolated intramural hematoma (IMH) and its known
Presence of a patent left internal mammary artery to
association with aortic dissection, we recommend close coronary artery bypass graft
observation and hypertension control with follow-up im- Termination of the left vertebral artery into the posterior
aging as the initial management of patients with asymp- inferior cerebellar artery
tomatic IMH. Level of recommendation: Grade 1 Absent, atretic, or occluded right vertebral artery
(Strong), Quality of Evidence: B (Moderate) Patent left arm arteriovenous shunt for dialysis
58S Upchurch et al Journal of Vascular Surgery
January Supplement 2021

Prior infrarenal aortic operation or endovascular aneu- Recommendation 27: We recommend minimizing the
rysm repair with previously ligated or covered lumbar dwelling time of large or occlusive iliofemoral artery
and middle sacral arteries sheaths to decrease the risk of spinal cord ischemia
Planned extensive coverage ($15 cm) of the DTA and lower extremity ischemia that can lead to postoper-
Hypogastric artery occlusion or significant occlusive ative compartment syndrome or rhabdomyolysis. In
disease cases in which a large sheath must be left in place for
Presence of aneurysm disease in the young patient, for a prolonged time, it can be withdrawn into the external
whom future therapy involving the distal thoracic aorta iliac artery to allow antegrade flow into the ipsilateral in-
may be necessary
ternal iliac artery. Meticulous postoperative vigilance to
detect inadequate lower extremity perfusion or
Recommendation 21: For patients with acute thoracic
compartment syndrome should be routine. Level of
emergencies, where TEVAR is required urgently and
recommendation: Grade 1 (Strong), Quality of Evi-
coverage of the LSA is necessary, it is suggested that
dence: B (Moderate)
revascularization should be individualized and
Recommendation 28: We recommend pre-emptive
addressed on the basis of the patient’s anatomy and ur-
superior mesenteric artery (SMA) stenting with a
gency of the procedure. Level of recommendation:
balloon-expandable stent in cases of >50% stenosis of
Grade 2 (Weak), Quality of Evidence: B (Moderate)
the SMA in the following conditions: before or after celiac
Recommendation 22: We recommend preprocedural
artery (CA) coverage or encroachment, with TEVAR that
TEVAR planning to include sizing and landing sites
is encroaching on the SMA origin, or in any patient other-
before the case to minimize procedural contrast material
wise considered at high risk for post-TEVAR mesenteric
use. If available, intraoperative CTA overlay technology
ischemia. Level of recommendation: Grade 1 (Strong),
and intravascular ultrasound should be used to minimize
Quality of Evidence: B (Moderate)
use of contrast material. Level of recommendation:
Recommendation 29: In anticipation of high risk for CA
Grade 1 (Strong), Quality of Evidence: B (Moderate)
territory ischemia (nonvisualization of CA collateral
Recommendation 23: We recommend nonionic, branches by CTA or dedicated SMA angiography), we
hypo-osmolar contrast material with attempts at mini- recommend open or endovascular revascularization of
mizing intra-arterial contrast agent use, especially in pa- the CA before TEVAR. Level of recommendation: Grade
tients at high risk for contrast-induced nephropathy. 1 (Strong), Quality of Evidence: B (Moderate)
Level of recommendation: Grade 1 (Strong), Quality of Recommendation 30: If an open approach for access is
Evidence: B (Moderate) used, we recommend transverse or oblique incisions in
Recommendation 24: Depending on the patient’s performing open femoral access for TEVAR. Level of
corporal density and the capacity of the X-ray equip- recommendation: Grade 1 (Strong), Quality of Evi-
ment available, we suggest diluting contrast material dence: B (Moderate)
in the power injector when possible (typically to 50% Recommendation 31: We recommend using ultra-
or 70%). Adjustments in injection volume and time sound guidance for percutaneous access to improve pro-
(faster injection of smaller doses) can usually compen- cedural success and to decrease the rate of major
sate when additional visibility is required. Level of complications. Level of recommendation: Grade 1
recommendation: Grade 2 (Weak), Quality of Evi- (Strong), Quality of Evidence: B (Moderate)
dence: C (Low) Recommendation 32: We recommend that percuta-
Recommendation 25: We suggest the use of on-table neous access for TEVAR is safe and an acceptable alter-
mapping software options on fixed-imaging X-ray native to open common femoral artery exposure if
systems, such as roadmapping and computed tomogra- certain anatomic criteria are met (eg, diameter of com-
phy (CT) fusion or overlay reference, to aid in locating mon femoral artery, lack of front wall calcium). Level of
target landing sites and to minimize need for repeated recommendation: Grade 1 (Strong), Quality of Evi-
injections. If available, CT overlay capability is extremely dence: B (Moderate)
useful, especially in cases in which location and Recommendation 33: We recommend the use of iliac
cannulation of branches will be needed. Level of conduits or direct iliac/aortic punctures for TEVAR deliv-
recommendation: Grade 2 (Weak), Quality of Evidence: ery to facilitate access in patients with small (relative to
B (Moderate) the chosen device), tortuous, or calcified iliac vessels.
Recommendation 26: To decrease the risk of athe- The decision to perform a conduit should be made in
roembolization, we recommend minimizing intra-aortic the preoperative setting, when possible. Level of recom-
wire, catheter, and endograft manipulation in the aortic mendation: Grade 1 (Strong), Quality of Evidence: B
arch and at or above the visceral/renal arteries, especially (Moderate)
in patients with significant aortic atheromatous disease Recommendation 34: We suggest that endoconduits
or thrombus. Level of recommendation: Grade 1 to facilitate access for TEVAR are an acceptable alterna-
(Strong), Quality of Evidence: B (Moderate) tive to an open iliac conduit in some cases, but few
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data comparing them with an iliac conduit or long-term possible volume-outcome relationship, related to repair
data describing their outcomes over time are available. of TAA.
Level of recommendation: Grade 2 (Weak), Quality of
Evidence: C (Low) DOCUMENT REVIEW AND APPROVAL
Recommendation 35: We recommend TEVAR over The committee developed the practice guideline by
open repair for the treatment of ruptured DTA when assigning members to create primary drafts of each sec-
anatomically feasible. Level of recommendation: Grade tion of the document based on the aforementioned
1 (Strong), Quality of Evidence: B (Moderate) outline, highlighting specific areas where recommenda-
Recommendation 36: We recommend contrast- tions were needed and appropriate. Each section was
enhanced CT scanning at 1 month and 12 months after then placed into a single document, compiled, reviewed,
TEVAR and then yearly for life, with consideration of and revised by the writing group, led by the Chair. All
more frequent imaging if an endoleak or other abnor- guideline recommendations were reviewed by the full
mality of concern is detected at 1 month. Level of recom- committee and finalized through an iterative, consensus
mendation: Grade 1 (Strong), Quality of Evidence: B process. In considering available treatment modalities to
(Moderate) be included in the final draft, we evaluated only options
currently available to patients and physicians in the
United States.
DEVELOPMENT OF GUIDELINES The Grading of Recommendations Assessment, Devel-
The Society for Vascular Surgery (SVS) thoracic opment, and Evaluation (GRADE) framework was used
endovascular aortic repair (TEVAR) guidelines commit- for determining the quality of evidence and the strength
tee was created by first soliciting interest among of recommendation, as previously reported.1 The quality
members of the SVS. The committee and Chair of evidence is rated high (A), moderate (B), or low (C).
were then chosen by the SVS to ensure that the This rating is based on the risk of bias, precision, direct-
number of authors without documented conflicts of ness, and consistency. The strength of recommendation
interest was greater than or equal to the number is graded on the basis of the quality of evidence, balance
with reported conflicts of interest. Importantly, these between benefits and harms, patients’ values, prefer-
guidelines are specific for lesions isolated to the ences, and clinical context. Recommendations are
descending thoracic aorta (DTA) that require coverage graded strong (1) or weak (2). The term we recommend
of zones 2 to 6.3 Those patients with aortic disease is used with strong recommendations, and the term
within the aortic arch requiring coverage at or prox- we suggest is used for weak recommendations. Some
imal to the left carotid artery (zone 0 or zone 1) are statements are labeled good practice statements.4 These
excluded from these guidelines. Furthermore, whereas are statements that did not have direct supporting evi-
we included management of the celiac artery (CA) dence but had ample indirect evidence and would be
when coverage is required for distal seal and fixation, considered by many surgeons as surgical principles.
the subject of management of any other visceral ar- Some statements are labeled implementation remarks.
teries was excluded from these guidelines. These are technical suggestions that aim to explain
An outline developed by the writing group included and to implement the preceding recommendation.
the following: anatomy of the thoracic aorta; aortic Finally, the SVS Document Oversight Committee peer
pathologic processes to be covered, that is, thoracic reviewed the document twice and provided content
aortic aneurysms (TAAs) and acute aortic syndromes and methodology expertise. The document was then
limited to penetrating aortic ulcer (PAU) and intramu- revised and sent to the Executive Committee and
ral hematoma (IMH), exclusive of traumatic injuries received final endorsement.
and dissection; diagnostic findings; and comparison of
the advantages and disadvantages of available imaging METHODOLOGY AND EVIDENCE REVIEW
modalities in various settings. Further topics included In association with the TEVAR for TAA guideline group
the perioperative management of patients with document and recommendations, a systematic review
thoracic aortic disease, specifically mitigation of the and meta-analysis were conducted to evaluate the effec-
perioperative risk of spinal cord ischemia, stroke, and tiveness of TEVAR and open repair in patients with iso-
renal failure, and evidence-based recommendations lated TAA.5 The data sources for this evidence review
regarding the management of the left subclavian ar- included PubMed, Ovid MEDLINE, Ovid Embase, EBSCO
tery (LSA) and CA when coverage of those vessels is CINAHL, and Scopus, which were searched from each da-
deemed necessary for “successful” repair. Additional tabase’s inception to January 29, 2016. Observational
recommendations focused on arterial access, differen- studies that compared the two approaches in adults
tial management of elective and urgent/emergent with TAA and reported 30-day mortality or procedure
TAA, and optimal surveillance intervals after TEVAR. complications were selected. Data were extracted and
Finally, we considered special problems, including appraised by two reviewers independently. Random
60S Upchurch et al Journal of Vascular Surgery
January Supplement 2021

effects meta-analysis was used to estimate odds ratio (OR) natural history, further clouding our knowledge.22
and 95% confidence intervals (CIs). This document pro- Importantly, TAAs often occur in patients with multiple
vided evidence that TEVAR reduced the risk of mortality comorbidities, such as hypertension and atherosclerosis,
in both intact (OR, 0.6; 95% CI, 0.36-0.99) and ruptured over a wide range of ages. Therefore, patients often suc-
(OR, 0.58; 95% CI, 0.38-0.88) settings. In addition, para- cumb to other disease processes, such as cancer or cor-
plegia risks and pulmonary complication rates were lower onary artery disease, highlighting the importance of
with TEVAR compared with open repair for isolated TAA. preoperative surgical decision-making in the setting of
the largely unknown natural history of TAA.
EPIDEMIOLOGY AND RISK FACTORS Regardless, initial studies from the 1970s by McNamara
Thoracic aortic disease is an important public health and Pressler23 documented that approximately 40% of
issue.6-10 Although abdominal aortic aneurysms (AAAs) TAA patients who did not undergo surgical repair died
and ascending aortic aneurysms are more common, of rupture, whereas 32% died of other cardiovascular dis-
descending TAAs and thoracoabdominal aortic aneu- eases, with a mean survival of <3 years after TAA diag-
rysms (TAAAs) are not rare, with an estimated incidence nosis. During an extended period of observation, >90%
of 6 to 10 cases per 100,000 person-years.5,10 Olsson et al11 of patients with unrepaired aneurysms suffered aortic
examined the prevalence of TAA from 1987 to 2002 in rupture, with 68% of ruptures occurring >1 month after
patients with thoracic aortic dissections (ADs) or aneu- the diagnosis.23,24 A more recent (2002) review25 found
rysms in Sweden. Of 14,229 individuals with thoracic the 5-year survival rate for patients with a 6.0-cm TAA
aortic disease, the diagnosis was made in 11,039 (78%) to be 54%, with a risk for rupture of 3.7%/y and a risk
before death. The incidence of thoracic aortic disease for death of 12%/y. The investigators found a similar me-
rose by 52% in men and 28% in women to reach 16.3 dian survival in patients with untreated TAA of only
and 9.1 per 100,000 per year, respectively. The authors 3.3 years. In a natural history study by Crawford and
concluded that the prevalence and incidence of thoracic DeNatale26 of TAA patients who were not candidates
aortic disease were higher than previously reported and for open surgery, the survival rate was just 24% at 2 years,
have been steadily increasing. The rising prevalence of with more than half the deaths related to aneurysm
TAA has been attributed to a number of factors, rupture. Chronic obstructive pulmonary disease (COPD)
including improved imaging techniques, an aging popu- was noted in 80% of the subgroup with rupture. Similar
lation, and increased patient and physician awareness.12 studies in patients with small infrarenal AAAs have
confirmed COPD as a significant risk factor for rupture.27
Population affected. TAA is primarily a disease of the Cambria et al28 followed up a series of 57 patients with
elderly. The average age of patients with TAA is 65 years TAA, including those who were not considered operative
at diagnosis, with a male to female ratio of 1.7:1.10 In candidates. The authors found that an aneurysm
contrast, in patients with AAA, the mean age is 75 years, >5 cm (P ¼ .05) and both COPD and chronic renal failure
with a male to female ratio of 6:1.13 TAAs clearly have a were associated with rupture (P ¼ .06). Griepp et al29
genetic component, with >20% of patients having a first- studied 165 patients with TAAA who did not undergo sur-
degree relative affected by aneurysm disease.14-16 gery, finding that about 20% experienced aneurysm
Risk factors for disease and rupture. Many risk factors rupture. Significant risk factors included older age,
are common to both AAA and TAA patients, including COPD, continued pain, and aortic diameter. Patients
hypertension, smoking, and atherosclerosis in other arte- with AD ruptured at smaller aortic diameters than did
rial beds.10,17-19 Systemic hypertension, especially those with degenerative aneurysms.
elevated diastolic blood pressure >100 mm Hg, has been Practice Statement: More research focused on the
associated with aortic growth and rupture.20,21 Although pathogenesis and clinical care of patients with isolated
most often described as degenerative in etiology, up to TAA is required.22-29 (Ungraded good practice
20% of patients have TAAs that are the sequelae of statement)
chronic AD. Importantly, for this document, TAA related
to chronic type B ADs and those associated with inheri- THE THORACIC AORTA: ANATOMY AND
ted connective tissue disorders are intentionally CLASSIFICATIONS
excluded and are the subject of future SVS documents. Anatomy of the thoracic aorta. The thoracic aorta is
divided into the aortic root, ascending aorta, aortic
Natural history and rupture rate of TAA. Published arch, and descending aorta. The size of the thoracic aorta
data on the natural history of isolated TAAs is not as increases from the root to the diaphragm, with an
readily available as it is for infrarenal AAA, partially related average size between 2 and 3 cm; it is approximately
to their much less frequent occurrence. Also, data 10% smaller in women.6,30 Critically at risk during
regarding isolated TAA have historically been combined TEVAR are the multiple spinal cord branches that may
with TAAA and with aneurysm associated with dissec- be covered by the endograft after emerging as dorsal
tion, each of which is likely to have its own unique branches from the intercostal arteries. These critical
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Volume 73, Number 1S

branches collateralize as the anterior spinal artery, which

then travels along the axis of the cord. Multiple vessels
supply blood flow to the spinal cord, including the sub-
clavian and vertebral arteries, intercostal arteries, su-
preme intercostal artery of Adamkiewicz, lumbar
arteries, and iliolumbar branches of the internal iliac
(hypogastric) arteries.31,32
There are anatomic aortic arch variations. These varia-
tions often are not manifested during childhood but
are recognized later in life. Many of these variations are
often corrected in childhood if they are incompatible
with a normal life span. The most common anatomic
variation is a “bovine” arch, in which one or more of the
great vessels arise from a common trunk. A second com-
mon variable, the aberrant right subclavian artery (arteria
lusoria), arises distal to the LSA and travels posterior to
the esophagus to the right arm. The path of these aber-
rant arteries can vary in their relation to the trachea and
esophagus. Other common variants include an aberrant
LSA, which often is seen in the setting of a right-sided
arch, and a thyroid ima branch, which arises directly
from the aortic arch and travels to the thyroid gland. Var-
iations in the origin of the vertebral arteries are also com-
mon, with the most common variation involving a
vertebral artery arising directly from the aortic arch.

Classifications of the zones and arch. The aorta can Fig 1. Zones of the thoracic aorta.3
be divided into 11 zones, 6 of which are in the
thoracic aorta, which are useful for describing the
segment of the vessel and the potential branches are variably associated with wall thinning, loss of elastic
that may be covered or replaced during repair and muscle fibers in the aortic media, accumulation of
(Fig 1).3 The utility of these zones in comparative mucopolysaccharide cysts between the fibers, and sub-
research is well described in the SVS Ad Hoc Com- sequent wall expansion. Common risk factors include
mittee on TEVAR Reporting Guidelines.3 Zone 2 is the hypertension and connective tissue disease. Atheroscle-
segment that includes the LSA, whereas zone 3 is the rosis, on the other hand, is typically characterized by
considered the proximal DTA. Zone 4 is the straight intimal plaques composed of variable combinations of
portion of descending aorta. Zone 5 is the segment fibrous tissue and lipid with calcification. Inflammation
of the DTA that terminates above the CA. The manifested by the accumulation of macrophages and
remainder of the aorta lies within the abdomen, with lymphocytes and their secretory products contributes
zone 6 involving the celiac aorta (Fig 1). Aortic arch to the progression of disease.
anatomy also can be critical, especially in the setting
Aortic vasculitides and inflammatory diseases. Inflam-
of a type III arch (Fig 2).33
matory aortitis is characterized by the presence of
Practice Statement: Future publications and reporting
inflammation of the adventitia and media.34 Histologic
of TEVAR management should include classifications
findings may show thickened adventitia with infiltration
identifying the location of aneurysms and presence or
of adventitia and media with clusters of plasma cells and
absence of PAUs with or without IMH as well as the
lymphocytes.
zones and arch type to aid in comparative studies for
Takayasu (necrotizing) aortitis usually is manifested as
the prediction of patient outcomes after interventions.
panaortitis with granulomatous inflammation and ste-
(Ungraded good practice statement)
nosis of the aortic arch and its major branches.34 Initially,
the inflammation is around the vasa vasorum and at the
THORACIC AORTIC HISTOPATHOLOGY medial-adventitial site and advances into the intima.
Thoracic aneurysm and atherosclerotic disease. The Rapid and severe inflammation can lead to the loss of
most common histopathologic feature of TAA is elastic smooth muscle cells and may advance to produce aortic
tissue fragmentation and loss of smooth muscle cells, arch syndrome, segmental stenosis, occlusion, and aneu-
resulting in the collection of matrix material in the area rysm. Disintegration of elastic fibers is prominent, as are
of disintegration. These medial degenerative changes reactive fibrosis and increased ground substance within
62S Upchurch et al Journal of Vascular Surgery
January Supplement 2021

Fig 2. Classification of the aortic arch. CCA, Common carotid artery. (Reproduced from Madhwal S, Rajagopal V,
Bhatt DL, Bajzer CT, Whitlow P, Kapadia SR. Predictors of difficult carotid stenting as determined by aortic arch
angiography. J Invasive Cardiol 2008;20:200-4. Permission from HMP Global.)

the intima. The histologic hallmark of Takayasu aortitis is It is speculated that the vasa vasorum is responsible for
multifocal medial laminar necrosis rimmed by macro- IMH, with elevated pressures in the vasa vasorum leading
phages and occasional giant cells. Quiescent or “burnt to rupture within the aortic wall. Subsequently, progres-
out” Takayasu disease is characterized by dense adventi- sion and eventual rupture into the intima might occur,
tial fibrous thickening and marked medial fibrosis with leading to typical AD. Studies examining the vasa vaso-
loss of the normal lamellar structure. rum have also suggested that hyperplasia leading to
Giant cell arteritis is a systemic vasculitis characterized chronic, occlusive disease within the aortic wall can
by focal, transmural granulomatous inflammation with lead to chronic medial ischemia and degeneration. The
giant cells, intimal thickening, and infiltrates of mononu- complex pathologic processes of PAUs and IMH have
clear cells, neutrophils, and eosinophils.34 This manifesta- been well described,37-39 and management decisions
tion is called granulomatous arteritis. The key can often be complex, depending on the clinical presen-
characteristic of granulomatous arteritis is the segmental tation and anatomic location, among other important
spread of inflammatory infiltrates, made up of T cells and factors.
histiocytes, that results in “skip lesions.” Both Takayasu
Mycotic aneurysms and aortoesophageal and aorto-
aortitis and giant cell arteritis are large-cell vasculitides
bronchial fistulas. A mycotic (or infected) aneurysm is
that appear to be the target of new medical manage-
defined as an infectious break in the wall of an artery
ments that include the use of targeted biologics.35
with formation of a blind, often saccular outpouching
PAU, IMH, and AD. PAU and IMH, a complex spectrum that is contiguous with the arterial lumen. Controversy
of aortic disease, are unique but often intertwined path- has existed as to the exact mechanisms by which pri-
ologic processes. This document is not intended to pro- mary mycotic TAAs occur; they may be due to hematog-
vide a review of AD as it will be reviewed in separate enous dissemination of microorganisms, direct
SVS guidelines. involvement of the intima, or extension from a nearby
Briefly, an atherosclerotic plaque can ulcerate and septic focus. An intimal disruption, such as in atheroscle-
result in a limited dissection or PAU.36 The ulceration rotic plaque, may be a site of bacterial lodgment, and
penetrates the internal elastic lamina, resulting in hema- histologic specimens have often demonstrated neutro-
toma formation within the media. The plaque may pre- philic infiltration and atherosclerotic change in the
cipitate a localized intramedial dissection associated same aortic wall. Pre-existing trauma or aneurysm may
with a variable amount of IMH within the aortic wall, also facilitate the onset of the infectious process. Histo-
which can spread into the adventitia, forming a pseudoa- pathologic findings consist of variable elastic fiber
neurysm or causing rupture. PAUs are typically not aneu- degeneration, partial or complete lumen obliteration,
rysmal but can occur concurrently with or in the absence compensatory fibrosis with increased thickness of the
of an aortic aneurysm, dissection, or IMH. aortic wall, and perivascular chronic infiltrate. It is
IMH can also develop in apparent isolation in patients important to exclude infection in all saccular TAAs as
with mild or no atherosclerosis. Aortic IMH may represent w93% of mycotic aneurysms have this appearance on
a variant of dissection, the so-called dissection in evolu- computed tomography angiography (CTA).40
tion, and is characterized by the absence of an intimal Aortoesophageal fistula is a rare and potentially fatal
flap, re-entrant tear, or double channel with false lumen. disorder that often is manifested after rupture of an
Journal of Vascular Surgery Upchurch et al 63S
Volume 73, Number 1S

aneurysm into the esophagus. The main etiologic factor Practice Statement: There is a relative lack of high-
contributing to aortoesophageal fistula is aortic disease, quality, long-term evidence on the use of TEVAR in the
with more than half of cases being secondary to rupture setting of arteritis,50 aortoesophageal51 and aortobron-
of an aneurysm of the DTA into the esophagus. Aorto- chial41 fistulas, coarctation,43 Kommerell diverticulum,52
bronchial fistula41 is also a rare but potentially life- and tumors.53 Therefore, no strong recommendations
threatening cause of hemoptysis if it is not adequately can be made. However, it is recognized that there are
treated. In younger patients, aortobronchial fistula is numerous institutional and database reports document-
more frequently seen secondary to surgical repair of ing the use of TEVAR in these settings. It is likely, espe-
congenital heart defects and aortic coarctation repair. cially in the setting of a ruptured thoracic aorta in
However, most aortobronchial fistulas originate from a association with these various pathologic processes,
descending atherosclerotic aneurysm or pseudoaneur- that TEVAR can play a lifesaving role. Finally, there is
ysm, which causes an erosion of the lung parenchyma also likely to be an advantage to TEVAR in these patho-
or tracheobronchial tree. logic processes in the noninfectious setting over the in-
Coarctation. Aneurysm formation can also develop in fectious ones. (Ungraded good practice statement)
patients late after surgical repair of aortic coarctation in DIAGNOSTIC EVALUATION OF THORACIC AORTIC
infancy and has been reported in numerous patients, DISEASE
with as many as 7% of patients developing “local” aneu- Thoracic aortic disease is increasingly an incidental
rysms.42 These aneurysms may be manifested as false, finding on studies performed for other indications
true, or dissecting.43 Cystic medial necrosis is a common because of the increasing use of cross-sectional imaging.
histopathologic feature observed in coarctation speci- Unlike abdominal ultrasound for screening for AAAs, there
mens from surgery or autopsy. This provides a pathologic is no low-cost modality that can be used to image DTA dis-
basis for the formation of aneurysms observed in these ease. Thus, there is more reliance on the patient’s history,
patients after balloon angioplasty or repair. including familial history, as well as on physical examina-
Kommerell diverticulum. Kommerell diverticulum is a tion findings to guide the ordering of radiographic tests
bulbous aortic dilation that is a remnant of incomplete to screen for thoracic aortic disease. Genetic testing lends
regression of an embryologic aortic arch; it is usually further support for diagnostic imaging. This section is
located at or near the origin of an aberrant subclavian ar- dedicated to the diagnostic evaluation of a patient with
tery (ASA).44 Aberrant right and left subclavian arteries (in DTA disease and also discusses specifics of the history
a right-sided aortic arch) are typically associated with a and physical examination as well as the preoperative
Kommerell diverticulum. The right ASA can arise distal to workup for patients before they undergo TEVAR.
the LSA and crosses through the posterior mediastinum
Values and preferences
behind the esophagus on its way to the right upper ex-
The committee acknowledges the lack of high-quality
tremity. The aberrant vessel has the potential to cause a
evidence supporting specific screening strategies, partic-
vascular ring around the trachea and esophagus, causing
ularly as it pertains to screening intervals. The committee
dysphagia and palsy of the recurrent laryngeal nerve due
placed high value on preventing catastrophic vascular
to anatomic position. Aneurysms rarely involve the ASA,
events and lower value on screening burdens (including
but they are associated with a high mortality rate if they
psychological burdens) and costs.
rupture. The risk for rupture or dissection is variable and
ranges from 19% to 53% in some of the case report se- History and physical examination in the evaluation of
ries.45 Surgical intervention should be considered when thoracic aortic disease
the diameter of the diverticulum exceeds 30 mm or the History of the patient’s illness. The clinical history
diameter of the descending aorta adjacent to the should be directed toward determining whether the pa-
diverticulum exceeds 50 mm.46-48 Histologic studies tient is at elevated risk for TAA and should receive further
demonstrated the presence of cystic medial necrosis in diagnostic evaluation. Most patients are older, with un-
the diverticulum wall, which would explain the reported controlled hypertension as a primary risk factor. In
high rates of AD and rupture associated with these younger patients, the clinical history should lead to an
diverticula. evaluation for secondary causes of severe hypertension,
Tumors. Primary malignant tumors of the aorta are including the use of legal and illicit sympathomimetic
extremely rare and exhibit enormous histologic hetero- drugs, especially in patients with syndromic and nonsyn-
geneity.49 They have been described as three distinct dromic genetic defects predisposing to aortic disease.
morphologic types: intraluminal, intimal, and adventitial. Patients with an inflammatory vasculitis, such as
Most of the cases are sarcomas, followed by malignant Takayasu disease, giant cell arteritis, and Behçet arteritis,
fibrous histiocytomas. Although intra-aortic biopsy is should also be considered at high risk for development
possible, these tumors are rarely expected or diagnosed of TAA. The history should also focus on history of previ-
before surgical exploration. ous aortic coarctation repair or a history of significant
64S Upchurch et al Journal of Vascular Surgery
January Supplement 2021

blunt trauma to the chest (especially those with a rapid Practice Statement: If there is a high clinical suspicion
deceleration injury). A detailed family history should be for an acute aortic process and the findings on the initial
taken to elicit a history of familial TAA and dissection. study were normal, a second imaging study may be
The past surgical history is carefully reviewed with spe- considered while alternative diagnoses are further
cific attention to prior procedures, including internal explored. (Ungraded good practice statement)
mammary artery to coronary artery transposition, upper
extremity arterial procedures, and hemodialysis access Preoperative workup in patients undergoing open sur-
procedures. The history should also focus on history of gical and endovascular repair
aortic valve disease, recent catheterization of the aorta, The preoperative cardiac assessments should follow the
and known TAA, especially in the ascending aorta and general recommendation of the American College of
aortic arch. Patients may also have symptoms attribut- Cardiology/American Heart Association (ACC/AHA)
able to compression of adjacent structures in the thorax, guidelines.2
such as dysphagia, shortness of breath, or hoarseness Emergent or urgent repair. In the presence of thoracic
related to stretching of the recurrent laryngeal nerves, aortic disease with rupture, preoperative imaging should
especially in the setting of a large or saccular proximal be adequate to evaluate whether the patient’s anatomy
DTA aneurysm. is amenable to endovascular repair. This typically consists
Physical examination. All patients should undergo a of CTA of the chest, abdomen, and pelvis (from above the
detailed physical examination designed to first detect clavicles to the femoral heads) to evaluate the proximal
the presence of a genetic syndrome associated with and distal seal zones and to evaluate for vascular access
AD or TAA (eg, Marfan, Loeys-Dietz, Ehlers-Danlos, or options. If coverage of the LSA is planned, CTA through
Turner syndrome). It is well known that these patients the head and neck is useful to determine the anatomy
with genetic syndromes have aneurysms in other of the vertebral arteries. In addition, identification of
anatomic locations, and thus palpation of the abdomen blood or effusions in the thoracic cavity may suggest
and popliteal fossa for aneurysms should be a routine that the lesion to be treated is acute in nature. CTA
part of the physical examination. may also be useful in the setting of aortoesophageal
The history and physical examination should also be and aortobronchial fistulas to determine the best way
focused on identifying other factors, such as angina or to approach the patient and to determine additional in-
COPD, that might preclude the patient from undergoing terventions (eg, esophagectomy, lung resection) that
TEVAR, especially in the setting of general anesthesia. may be needed.
Physical examination should also include a pulse evalua- Elective repair. Preoperative evaluation in the elective
tion, with special attention paid to the presence of setting consists of cardiac risk stratification and includes
palpable femoral pulses for potential access sites to weighing of the patient’s inherent clinical risk with the
deliver the TEVAR. risk of surgery. This algorithm is well detailed in the
Diagnostic studies and imaging in symptomatic pa- 2014 ACC/AHA guideline on perioperative cardiovascular
tients. Recommendation 1: In patients considered at evaluation and management of patients undergoing
low or intermediate risk for a TAA based on their history noncardiac surgery.2
and physical examination findings, we suggest chest X-
Assessment of left ventricular function
ray as the first radiographic test as it may identify an
Recommendation 3: For elective TEVAR cases, we sug-
alternative diagnosis for symptoms and may obviate
gest assessment of left ventricular function by transtho-
the need for additional aortic imaging. Level of recom-
racic echocardiography in a patient with dyspnea of
mendation: Grade 2 (Weak), Quality of Evidence: C
unknown origin or in a patient with known congestive
(Low)
heart failure with worsening dyspnea. Level of recom-
Recommendation 2: In patients considered at high risk
mendation: Grade 2 (Weak), Quality of Evidence: C
for symptomatic TAA or acute aortic syndrome, we
(Low)
recommend urgent imaging, usually CTA because of its
speed and ease of use for preoperative planning. Mag- Additional testing
netic resonance angiography (MRA) and transesopha- Practice Statement: Although there are few support-
geal echocardiography are also adequate for screening ing data, in trying to determine whether a patient with
to identify thoracic aortic disease but have limited appli- severe COPD is a candidate for open TAA repair or
cability in certain scenarios (discussed further later). TEVAR, the committee recommends considering pul-
Level of recommendation: Grade 1 (Strong), Quality of monary function testing preoperatively in an attempt
Evidence: B (Moderate) to determine baseline pulmonary function, especially if
Implementation remark: The choice of a screening general endotracheal anesthesia is being considered,
diagnostic study should be based on what is immedi- to determine risk of ventilator dependency postopera-
ately available at that institution. tively and ultimately to guide the choice of anesthesia
Journal of Vascular Surgery Upchurch et al 65S
Volume 73, Number 1S

(general vs local anesthesia). (Ungraded good practice head and neck is also needed to determine the anatomy
statement) of the vertebral arteries.60,61 Level of recommendation:
Grade 1 (Strong), Quality of Evidence: A (High)
RECOMMENDATIONS FOR IMAGING OF THE DTA Pixel spacing for modern CTA is submillimeter (0.5-
BEFORE TEVAR 0.75 mm), with a typically used slice thickness of around
The goal of this section is to review commonly available 1 mm, depending on scanner type and manufacturer.
aortic imaging modalities and their respective benefits. Routine computed tomography (CT) scans are often per-
The most critical findings and clinical suggestions for formed in 3- to 5-mm cuts, but three-dimensional plan-
optimizing image evaluation are presented. ning for endovascular intervention is best done with #2-
mm cuts.60 Given the acquisition method on most mod-
Chest radiography. Chest radiographs are particularly
ern CTA equipment, images can often be reformatted to
prone to observational and interpretive errors. A study
thinner cuts if the original data set is still available to do so.
analyzing common diagnostic errors, including aortic
Ideally, CTA should provide aortic opacification at a mini-
disease, in radiology found that 44% of errors occurred
mum of $250 Hounsfield units, $300 Hounsfield units uni-
in interpreting plain film radiographs, with 49% of these
formly being ideal. There is tremendous institutional
involving chest radiographs.54,55
variation in how this is achieved. There is further variation
A large aneurysm alters the normal transverse dimen-
based on the patient’s body habitus and cardiac output
sion of the mediastinum and blunts the normal inter-
and whether a test dose of contrast material vs bolus-
faces. Proposed radiographic criteria for a widened
tracking software is used. In general, fast injection rates
mediastinum include a mediastinal width >8 cm or a
and high concentrations of iodine are the general princi-
mediastinal to thoracic width ratio of $0.25. Other find-
ples that allow high-quality imaging. A reasonable estimate
ings include a left apical “cap,” fluid in the left hemo-
is that a total of 60 to 140 mL of nonionic iodinated contrast
thorax from a ruptured aneurysm, widening of the left
agent can be injected at a rate of 4 to 6 mL/s. This high injec-
or right paraspinal line or right paratracheal stripe,
tion rate necessitates a power injector, preferably with an
effaced aortic contour, anteroposterior window opacifi-
18- to 20-gauge intravenous line, usually in the antecubital
cation, tracheal deviation, left mainstem bronchus
fossa. Central lines are not desirable as they result in artifacts
depression, and deviation of a nasogastric tube to the
and make timing of the contrast agent bolus in the thoracic
right of the T4 spinous process54-56
aorta challenging.62,63
TAAs are typically located in the posterior mediastinum
Multiplanar reconstructions allow the aorta to be simul-
and associated with the cervicothoracic sign. This sign is
taneously visualized in coronal, sagittal, and axial planes.
based on the fact that the anterior mediastinum does
This allows a more nuanced understanding of the location
not extend above the clavicles. Therefore, any medias-
of branches and aortic curvature and a precise identifica-
tinal mass extending above the level of the clavicle
tion of seal zones. Centerline reconstructions are used to
with sharply defined borders delineated by an air-soft tis-
determine exact distances between branch arteries, and
sue interface is located in the middle or posterior
the length of the thoracic aorta can be measured as well.
mediastinum.57
The diameter of the aorta can be precisely determined
Practice Statement: The primary role of chest radio-
with centerline measurements as errors of parallax caused
graphs in the workup of acute aortic syndromes is the
by curvature are virtually eliminated.63-66
exclusion of other diagnoses. A chest radiograph may
Recommendation 5: We recommend routine use of
be completely normal despite the presence of PAU or
three-dimensional centerline reconstruction software
IMH. (Ungraded good practice statement)
for accurate case planning and execution in TEVAR.
CTA. CTA is the most widely used modality for definitive Level of recommendation: Grade 1 (Strong), Quality of
diagnosis of aortic diseases and has become essential for Evidence: B (Moderate)
planning aortic interventions, especially when it is used
in conjunction with postacquisition image processing MRA. MRA is not used for routine management of
and three-dimensional reconstruction software. This thoracic aortic disease primarily because of the speed
limits radiation exposure and intravenous contrast ma- and availability of CTA as well as ease of interpretation.
terial use. CTA should also include the femoral and iliac However, MRA can provide morphologic and blood
arteries as well as the abdominal aorta in addition to the flow information without use of iodinated contrast mate-
neck and chest.58 Advances in imaging techniques, rial or radiation exposure and therefore can play an
including electrocardiography-gated CTA, have been important role in the management of the thoracic aorta.
demonstrated to decrease the risk of motion artifact in Traditional methods for non-contrast-enhanced MRA,
the thoracic aorta.59 such as time-of-flight sequences, are being replaced by
Recommendation 4: If TEVAR is being considered, we newer techniques, such as spin-echo and steady-state
recommend fine-cut (#0.25 mm) CTA of the entire aorta free precession sequences.67 These provide high spatial
as well as of the iliac and femoral arteries. CTA of the resolution but are limited in their characterization of
66S Upchurch et al Journal of Vascular Surgery
January Supplement 2021

the aortic wall. Artifact can be present from embolization first-line therapy. For patients who do not respond to or
coils or from certain stent graft metallic components. are intolerant of beta blockers, calcium channel blockers
Contrast-enhanced MRA is typically performed with the or angiotensin-converting enzyme inhibitors or blockers
administration of gadolinium, which is administrated intra- can be used as alternatives or complementaries.73
venously with use of a power injector, with a dose of For patients with dyslipidemia, treatment with a statin to
0.1 mmol of gadolinium per kilogram of body weight. Im- achieve a target low-density lipoprotein cholesterol level
ages are acquired with a T1-weighted three-dimensional of <70 mg/dL is reasonable and may be helpful in control-
spoiled gradient-recalled echo sequence, usually during ling the progression of aneurysms.74 Counseling for smok-
breath-hold. As with CTA, the relationship between ing cessation, reduction of environmental tobacco
contrast material administration and image acquisition is exposure, referral to special programs for cognitive-
crucial. The source images can be reformatted in multiple behavioral therapy, initiation of pharmacotherapy, or,
planes with maximum intensity projections and volume preferably, multimodal management to achieve com-
rendering, and a three-dimensional centerline reconstruc- plete tobacco abstinence is recommended for patients
tion can be generated using the MRA data set.68,69 who have active tobacco use or exposure.75,76
Recommendation 6: We suggest contrast-enhanced Recommendation 8: As hypertension is a modifiable
MRA for preoperative planning for patients with severe risk factor for the development of aortic aneurysms and
allergy to iodinated contrast material. Level of recom- is associated with accelerated aortic growth and rupture,
mendation: Grade 2 (Weak), Quality of Evidence: C we recommend that blood pressure be managed to the
(Low) adherence of the ACC/AHA guidelines.2 Level of recom-
mendation: Grade 1 (Strong), Quality of Evidence: B
Intravascular ultrasound (IVUS). IVUS has become an (Moderate)
important adjunct in the endovascular treatment of the Recommendation 9: We recommend interventions for
thoracic aorta. The presence of thrombus, calcifications, smoking cessation in patients with thoracic aortic dis-
and poor aortic wall integrity can also be seen in the ease as even passive exposure may increase the risk of
setting of PAUs. IVUS adds significant value in treatment aortic rupture. Level of recommendation: Grade 1
of TAA by reducing intraoperative contrast material vol- (Strong), Quality of Evidence: A (High)
ume and radiation use. It also allows precise intraopera-
tive measurement of distances and diameters of the Open repair vs TEVAR for TAA
aorta, adding to the preoperative CTA measurements, Until recently, surgical management for elective TAA
especially in angulated aortas.70,71 repair required major open surgery, with a significant
Recommendation 7: We recommend IVUS use in risk for perioperative morbidity and mortality. Centers
TEVAR for TAA to assess landing zones when cross- of excellence report impressively low mortality and spi-
sectional imaging is of poor quality, a more detailed eval- nal cord ischemia rates in elective cases of 4.8% and
uation of landing zones or branch vessel origins is 4.6%, respectively.77 In tandem, the mortality after open
needed, or a decrease in contrast material use is desired. surgical treatment of ruptured TAA in highly specialized
Level of recommendation: Grade 1 (Strong), Quality of practices has been reported to be close to 26%.78 In
Evidence: B (Moderate) contrast, the overall mortality rates in the United States
for elective, open repair of TAA is approximately 22%,79
PERIOPERATIVE MANAGEMENT AND OPERATIVE
highlighting the effect that surgeon and center experi-
DECISION-MAKING
ence has on overall outcomes of these patients. However,
Perioperative medical management data have consistently demonstrated that TEVAR of iso-
Medical management of patients with thoracic aortic lated TAA is a safe alternative to open surgery and is asso-
disease has been thoroughly described.6 This includes ciated with a substantially lower morbidity and mortality
control of hypertension, statin therapy/lipid optimization, and a shorter hospitalization.80,81 Large studies designed
and smoking cessation. Medical therapy with antihyper- to evaluate the long-term (>5 years) outcomes have only
tensive agents is widely used as a first-line treatment in recently become available.82 Only one small series of
patients with aortic disease.72 Blood pressure control is thoracic PAU showed a potential benefit to TEVAR
based on anti-impulse therapy to limit the ventricular because of a similar long-term survival (w50% at 10 years
ejection force and the aortic wall stress and is especially in both groups), with lower morbidity in the TEVAR
important in cases of symptomatic aneurysms or acute group, despite being done in patients with a higher
aortic syndromes. The goal of therapy is to reduce the number of preoperative comorbidities.83 In addition,
systolic blood pressure to <20 mm Hg and the heart only recently has there been an attempt to establish a
rate to <60 beats/min when possible before, during, risk scoring system specifically developed to predict mor-
and after TEVAR (see exceptions in recommendations tality in patients undergoing TEVAR.84,85
for spinal cord protection). This is usually achieved with A Cochrane review compared thoracic stent grafting to
intravenous beta blockers (or alpha/beta blockers) as open surgery for TAA and concluded that although stent
Journal of Vascular Surgery Upchurch et al 67S
Volume 73, Number 1S

Table. Instructions for use of current thoracic devices

Iliac/femoral Aortic outer Proximal landing Distal landing
Manufacturer Name diameter, mm diameter, mm zone, mm zone, mm
W. L. Gore & Conformable Thoracic 4-8.7, depending on sheath 16-42a $20 $20
Associates91 Aortic Graft (c-TAG)
Medtronic92 Valiant Captivia 7.3-8.3, depending on sheath 18-42 $20 $20
Cook Medical 93
Zenith Alpha b
6.0-7.7, depending on graft size 22-42 $20 $20
Boltonc Medical94 Relay 7.3-8.7, depending on sheath 19-42 15-25 15-25
a
Gore measures inner aortic diameter for graft sizing.
b
Cook recalled all Zenith Alpha TEVAR grafts with proximal or distal diameter of 18 to 22 mm and recalled the indication for blunt traumatic aortic
injury on March 22, 2017.95
c
Now Terumo.

grafting of the thoracic aorta is technically feasible and should take into account the comorbidities of the pa-
nonrandomized studies suggest reduction of early tients, their expected longevity, and risk factors for a poor
adverse outcomes, such as paraplegia, mortality, and outcome after TEVAR.
hospital stay, high-quality randomized controlled trials Recommendation 11: We recommend TEVAR in
assessing clinically relevant outcomes including open asymptomatic patients with a descending TAA when
conversion, aneurysm exclusion, endoleaks, and late the maximum aneurysm diameter exceeds 5.5 cm in
mortality are needed.86,87 In addition, although there “low-risk” patients with favorable aortic anatomy. Level
are no randomized, controlled prospective trials of recommendation: Grade 1 (Strong), Quality of Evi-
comparing open and endovascular TAA repair and prob- dence: B (Moderate)
ably never will be, industry-sponsored trials and registry Recommendation 12: We suggest using higher aortic
data (Table) suggest clinical equipoise in centers experi- diameter thresholds for TEVAR in patients deemed to
enced in both techniques.77-81,84,85,88-95 have a particularly high risk of death, renal failure, or
Recommendation 10: In patients who could undergo paraplegia from the procedure, where the benefit of
either technique (within the criteria of the device’s in- treatment is lower than the risk posed by the natural his-
structions for use), we recommend TEVAR as the tory of the TAA. Level of recommendation: Grade 2
preferred approach to treat elective DTA aneurysms, (Weak), Quality of Evidence: C (Low)
given its reduced morbidity and length of stay as well TEVAR for IMH and PAU. As mentioned previously,
as short-term mortality. Level of recommendation: IMH, PAU, and AD may be similar pathologic processes
Grade 1 (Strong), Quality of Evidence: A (High) along a spectrum of aortic disease or may occur in isola-
tion, and therefore a discussion of the use of TEVAR for
Indications for repair dissection will be undertaken in another SVS document.
TEVAR for TAA. Untreated 6.0-cm TAAs have a 5-year Patients with asymptomatic, acute IMH may often be
survival of 54%, yielding a 3.7%/y risk for rupture and a managed conservatively with optimal medical therapy
risk of dying of w12%/y.25,96 A prospective database of in an intensive care setting. According to a contempo-
>1600 TAAs and ADs found that an aneurysmal thoracic rary systematic review of 925 patients with IMH, the pre-
aorta grows an average of 0.10 cm/y (0.07 cm for the dictors of complications include persistent pain,
ascending aorta and 0.19 cm for the DTA).22,96 In saccular hemodynamic instability, maximum aortic diameter
aneurysms, which may have a higher risk of rupture, >45 mm, IMH wall thickness >10 mm, presence of
TEVAR may be justified at a diameter <6.0 cm even ulcer-like projections, pleural effusion or hemomedias-
though high-quality data are not readily available. Data tinum, and periaortic hemorrhage.97 The 3-year aorta-
suggesting that lower thresholds for repair of the DTA in related mortality was 5.4% with medical treatment,
women are also not readily available as aneurysm dis- 23% with open surgery, and 7.1% with endovascular
ease in the thoracic aorta is rarer than in the abdominal therapy.97 Because of the dynamic nature of IMH and its
aorta. In making treatment recommendations, the pa- association with AD (AD in evolution), close observation
tient’s overall medical condition and risk profile should and hypertension control with follow-up imaging are
be considered. For patients at higher risk for elective warranted.
repair, a larger aortic diameter threshold may be more Recommendation 13: Because of the dynamic nature
appropriate in considering their expected surgical of isolated IMH and its known association with AD, we
complication rate. In addition, data are lacking regarding recommend close observation and hypertension control
rapid aneurysm expansion and what size threshold over with follow-up imaging as the initial management of pa-
time is considered accelerated growth. Therefore, TEVAR tients with asymptomatic IMH. Level of recommenda-
based on “rapid expansion” should be individualized and tion: Grade 1 (Strong), Quality of Evidence: B (Moderate)
68S Upchurch et al Journal of Vascular Surgery
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Recommendation 14: We recommend TEVAR in pa- theoretically allow neurologic evaluation of the patient’s
tients with IMH or PAU who have persistent symptoms lower extremities.107
or complications or show evidence of disease progres- Arterial lines, large-bore venous access, and cerebrospi-
sion on follow-up imaging after a period of hypertension nal fluid (CSF) drains are placed before TEVAR. The ne-
control. Level of recommendation: Grade 1 (Strong), cessity for each of these depends on the complexity of
Quality of Evidence: B (Moderate) the repair, the risk of spinal cord ischemia, the planned
The natural history of and indications for repair in duration of the procedure, and the likelihood of signifi-
patients with PAUs are controversial, but they have cant blood loss. Other adjunctive techniques performed
been found in one series to grow 2 mm/y in their during TEVAR, such as somatosensory and motor evoked
maximal aortic size and length while growing an potential monitoring, rapid arterial pacing, or pharmaco-
average of only 1.2 mm/y in depth.98 The presence of logically induced hypotension, may be used as well.
symptoms, an associated IMH, and an increase in pleural Practice Statement: Comparative, high-quality data
effusion appear to be risk factors for complications.83,99 regarding the use of local anesthesia vs general anes-
Treatment with TEVAR is indicated for patients who thesia during the performance of TEVAR are lacking,
are symptomatic despite best medical therapy or have and it is typically physician or hospital dependent. (Un-
an increase in pleural effusion. The threshold for inter- graded good practice statement)
vention for asymptomatic patients is also controversial. Spinal cord protection. Spinal cord injury (SCI) can be
According to one study, PAU depth >10 mm and diam- a devastating complication that has a profound impact
eter >20 mm are risk factors for progressive disease.99 on the benefit of the procedure, given the higher risk of
Recommendation 15: We suggest TEVAR in selected mortality if it occurs. Although up to 70% of patients
cases of asymptomatic PAU in patients who have at- will have some functional improvement after suffering
risk characteristics for growth or rupture. Level of recom- SCI, only 38% are reported to return to normal func-
mendation: Grade 2 (Weak), Quality of Evidence: B tion.108 Those patients who do not have functional
(Moderate) improvement have an abysmal prognosis, with mortality
Practice Statement: In the absence of clear and widely as high as 75% at 1 year.108,109
accepted parameters, the decision to intervene in Given these poor results after SCI, a number of preven-
asymptomatic patients with IMH and PAUs should be tion strategies have been employed to mitigate risk,
individualized. Asymptomatic patients treated for PAUs including maintenance of LSA and hypogastric
in the setting of a maximal aortic diameter <5.5 cm or patency,110 staging strategies for long-segment aortic
with PAUs <10 mm deep or <20 mm in diameter need coverage,111 prophylactic CSF drainage, anemia preven-
further study. (Ungraded good practice statement) tion, permissive hypertension, steroid and naloxone ther-
TEVAR for infected TAAs. Whereas the use of TEVAR apy,112 burst suppression, permissive hypothermia, and
to treat infected aortic diseases has often been reported hyperoxygenation therapy. Most successful centers
in single or small case series, there are no convincing employ a multimodal and systematic approach to SCI
long-term data to fully support it as a definitive ther- prevention, with detailed protocols on management of
apy. Although TEVAR can be effective when it is used to spinal drains, multidisciplinary coordination, and rescue
temporize ruptured infected TAA or life-threatening procedures for those presenting with delayed SCI.113
fistula with a hollow organ (ie, aortoesophageal and Techniques for spinal cord protection after thoracic
aortobronchial fistulas), patients with this clinical pre- aortic surgery have evolved significantly during the last
sentation have high morbidity and mortality regardless four decades.96 Paraplegia after TEVAR limited to the
of the subsequent management strategy.100-103 TEVAR DTA is uncommon (<5%) compared with open aneu-
may offer a more durable repair if the endograft is rysm repair, despite the observation that TEVAR invari-
pretreated with antibiotics, such as rifampin, but ably covers intercostal branches. This highlights the fact
there are limited data in widely disparate clinical that the cause of SCI after open and endovascular repair
scenarios.100,104,105 is multifactorial and not simply related to cessation of
Recommendation 16: We suggest TEVAR for symptom- intercostal artery perfusion. However, there are data
atic mycotic/infected TAAs as a temporizing measure, demonstrating that increased aortic coverage leads to
but data demonstrating long-term benefit are lacking. a higher risk of SCI, supporting the notion that the inter-
Level of recommendation: Grade 2 (Weak), Quality of costal arteries are in fact an important source of spinal
Evidence: C (Low) cord perfusion.114 Of note, protocols are published
describing the complex interaction between mean arte-
Choice of anesthetic and monitoring techniques rial pressure and spinal cord pressure.115
Anesthesia. It is technically feasible to perform TEVAR Somatosensory and motor evoked potentials permit
procedures percutaneously under monitored anesthesia continuous monitoring of the spinal cord’s function,
care with local anesthesia.106 Among other benefits of assist in the early detection of SCI, and are popular tech-
avoiding general anesthesia, local anesthesia may niques used in high-risk cases during open TAA repair or
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when patients are undergoing branched or fenestrated open AAA repair; compromised pelvic perfusion with
endovascular aneurysm repair (EVAR).116,117 They are diseased or occluded common or internal iliac arteries;
rarely used in the setting of simple TEVAR. diseased or occluded vertebral arteries; planned LSA
Indications for prophylactic CSF drainage catheter coverage; or deemed high risk by the operating surgeon).
placement during TEVAR are controversial, and CSF Level of recommendation: Grade 1 (Strong), Quality of
drains should be used as only one part of a multimodal Evidence: B (Moderate)
protocol to reduce the risk of SCI. Some authors recom-
mend selective CSF drain placement for only high-risk Management of the LSA and vertebrobasilar system
patients, whereas others perform CSF drain placement An adequate proximal landing zone requires coverage of
preoperatively routinely.113,117-119 Risk factors for SCI after the LSA in 26% to 40% of patients undergoing TEVAR.109,126
TEVAR include length of aortic coverage (especially In the first U.S. TEVAR regulatory trial,80 all patients under-
when it is in excess of 15 cm of the DTA) and existence went prophylactic LSA revascularization before TEVAR if
of infrarenal aortic disease.120 In addition to these the operative plan called for LSA coverage. Guidelines on
anatomic risk factors, chronic renal failure may also be LSA revascularization were published in 2009 by the
an important risk factor.121 According to one systematic SVS,127 yet there remains variability in this practice with
review, the incidence of SCI after TEVAR with and continued debate on the indications for revascularization.
without prophylactic CSF drain placement was 3.2% Some surgeons perform revascularization routinely, some
and 3.5%, respectively.122 In contrast, a 2016 systematic selectively, and some perform LSA revascularization only
review of the use of lumbar drains in open repair and if symptoms occur after TEVAR.127,128 There are four major
TEVAR (including three randomized trials) concluded concerns with coverage of the LSA: spinal cord ischemia,
that spinal drains prevent early SCI with an OR of 0.48 stroke, arm ischemia, and vertebrobasilar ischemia.
(95% CI, 0.30-0.76; P ¼ .002), absolute risk reduction of Spinal cord ischemia. Understanding the anatomy of
4.5%, and number needed to treat of 23 in favor of CSF the LSA branches and the critical anterior spinal artery
drainage.123 is important as the LSA provides inflow into the anterior
There are many differences in institutional protocols for spinal artery through multiple pathways. There is general
CSF drain management. They vary widely from where to consensus that patients with focal disease and who are
level the drain (earlobe or spinal exit site), draining to a treated with shorter (#15 cm) stent graft lengths are at
target pressure vs to a target volume, what the baseline lower risk for spinal cord ischemia.114,126 Data from the
pressure should be and the units (centimeters of water European Collaborators on Stent/graft Techniques for
or millimeters of mercury), and the maximum amount Aortic Aneurysm Repair (EUROSTAR) registry, one of the
of fluid that should be drained (per hour, per 4 hours, largest series with specific attention to TEVAR and
or per day) to avoid intracranial bleeding or herniation. anatomy, demonstrated rates of spinal cord ischemia
Other adjunctive methods of SCI risk reduction include and stroke as high as 8.4% when there was LSA coverage
the routine use of naloxone and steroids, avoidance of without revascularization compared with 0% in those
long-acting narcotics, and hemoglobin management patients who underwent prophylactic LSA revasculari-
strategies, which vary across centers.113,124 An often-used zation (P ¼ .049).109
hemoglobin target is >10 mg/dL, especially for patients After reports of lower spinal cord ischemia rates in
who have symptoms of SCI. Rescue protocols also exist, experimental, sequential, and progressive embolization
which include a further increase in systemic blood pres- of spinal vessels in animal models,129 many have advo-
sure to >100 mm Hg, a drop in the CSF drain pressure cated for staging the coverage of large segments of the
(often 5 mm Hg or 7 mm Hg), transfusion to a target he- aorta to allow preconditioning or even purposeful spinal
moglobin level of >10 mg/dL, and the use of steroids.125 artery embolization before extensive TEVAR.130
Recommendation 17: We recommend increasing Stroke. The incidence of stroke during and identified
perfusion pressure through controlled hypertension after TEVAR for TAA generally ranges from 3.2% to
(mean arterial pressure >90 mm Hg) as a component 6.2%,131 and it may be lethal in one third of these
of a spinal cord protection protocol in patients at high cases.132 However, this range may vary according to the
risk of SCI because of extensive coverage length indication for TEVAR. A meta-analysis of the Cook-
(>15 cm), poor hypogastric perfusion (occluded or signif- sponsored multicenter trials demonstrated even lower
icantly stenosed hypogastric arteries), or coverage of rates in certain populations of patients, with a 30-day
important collaterals (subclavian/hypogastric arteries). stroke rate of 0% in the 56 patients treated for PAU. It
Level of recommendation: Grade 1 (Strong), Quality of was also only 2.4% in the 329 patients treated for TAA.133
Evidence: B (Moderate) There is published consensus that coverage of the LSA
Recommendation 18: We recommend prophylactic is associated with higher risk of stroke with TEVAR,
CSF drainage for SCI protection in TEVAR cases that are despite the fact that the stroke may not always be in
deemed high risk (covering extensive length of descend- the posterior circulation. A series of 285 TEVAR patients
ing aorta; previous aortic coverage, including EVAR and showed that coverage of the LSA was associated with
70S Upchurch et al Journal of Vascular Surgery
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an 11% stroke rate compared with 3% when it was not coverage, although <40% of patients with symptoms of
covered.134 The current debate centers on what interven- arm ischemia underwent delayed LSA revasculariza-
tions may reduce this risk. Approaches to prevent stroke tion.140,141 Because presentation of ischemic symptoms
include careful manipulation of wires and catheters near of the arm is often delayed, with time to presentation
the carotid vessels, denitrogenation devices, accurate im- ranging from 2 days to 26 months, revascularization can
aging and positioning of devices, routine LSA revascular- typically be addressed on a less urgent basis.
ization, and thorough understanding of each patient’s Additional considerations. The Knowledge and
arch and cerebral anatomy. A systematic review of 27 Encounter Research Unit performed a systematic litera-
studies found a stroke rate of 5.6% associated with LSA ture review and meta-analysis relating to the effect of
coverage and a reduction to 3.1% with LSA revasculariza- LSA coverage on the morbidity and mortality of patients
tion (not statistically significant).135 In the Medtronic Out- undergoing TEVAR.142 This analysis found that coverage
comes of Thoracic Endovascular Repair (MOTHER) of the LSA without revascularization compared with
registry of 1010 TEVAR patients, stroke was 2.2% without coverage with revascularization was associated with
coverage of LSA, 9.1% with coverage and no revasculari- trends toward increased risk of spinal cord ischemia (OR,
zation, and 5.1% with LSA coverage and revascularization, 2.69; 95% CI, 0.75-9.68), anterior circulation stroke (OR,
supporting routine LSA revascularization.136 The largest 2.58; 95% CI, 0.82-8.09), arm ischemia (OR, 47.7; 95% CI,
systematic review and meta-analysis support these find- 9.9-229.3), and vertebrobasilar ischemia (OR, 10.8; 95% CI,
ings. A review137 published in 2017 evaluated the inci- 3.17-36.7). More data have been published since 2009,
dence of stroke in 2594 patients treated with TEVAR such as a large single-center series in which the com-
and found the incidence in patients when the LSA was bined stroke, paraplegia, and death rate comparing LSA
uncovered to be 3.2% (95% CI, 1.0-6.5). When the LSA revascularization with coverage alone is a striking 0% vs
was covered but revascularized, the stroke rate was 27.9% (P < .001).143 Additional findings from a 2017 report
5.3% (95% CI, 2.6-8.6) compared with 8.0% (95% CI, 4.1- revealed a higher 30-day stroke rate in cases in which the
12.9) when the vessel was covered without revasculariza- LSA was covered compared with when it was revascu-
tion. Despite these data, selective LSA revascularization larized (14.3% vs 1.9%, respectively; P ¼ .02).137 The
strategies are not embraced by some because of con- consistent nature of these findings (including another
cerns for prolonging the procedure, complications of meta-analysis144) supports elective LSA revascularization
revascularization operations, and a perception that pa- to lower the risk of stroke and paraplegia. Certain limi-
tients at elevated risk for subclavian artery ischemia can tations persist in the observational nature of these data,
be identified ahead of time.138 including heterogeneous patients, infrequent and
There are two scenarios in which LSA revascularization inconsistently defined outcomes of interest, and under-
should always be considered to reduce perioperative powered studies. Large databases often exclude specific
stroke, even in “selective” approaches. Most concerning populations, such as trauma patients, or do not capture
is when a nonrevascularized vertebral artery ends in the anatomic variables or staged LSA revascularization.145
posterior inferior cerebellar artery, which would risk LSA surgical revascularization is typically performed
causing inadequate flow through the circle of Willis with a left carotid-subclavian bypass, subclavian to ca-
into the posterior cerebral circulation.139 In addition, rotid transposition, or carotid-axillary bypass, with similar
with a dominant left vertebral artery (66%-75% of pa- patency (84%-96% at 5 years)128,146,147 for each technique.
tients) in the presence of an absent, atretic, or diseased On occasion, when the left vertebral artery arises directly
right vertebral artery, nonrevascularization of the LSA in- from the arch or is very proximal on the LSA, a separate
creases the risk for posterior cerebral ischemia. vertebral transposition or bypass is necessary. A transpo-
Arm ischemia and vertebrobasilar insufficiency. Left sition is relatively contraindicated when there is coronary
arm ischemia symptoms may range from none to a artery bypass from the LIMA as this would cause myocar-
frankly threatened limb. Special consideration should dial ischemia during subclavian artery clamping and,
be given to LSA revascularization and left arm perfusion potentially, difficulties in mobilizing the LSA cephalad if
for patients at risk of coronary ischemia due to a prior it is tethered by the LIMA graft.
left internal mammary artery (LIMA) to left anterior Complications of LSA revascularization, specifically in
descending artery coronary bypass graft as well as for the setting of TEVAR, have been studied. From the sys-
those with existing arteriovenous fistulas in the left arm. tematic review, the overall incidence of phrenic nerve
Although flow reversal in the vertebral artery is common injury was low at 4.4% (95% CI, 1.6%-12.20%).142 Woo
after LSA coverage, most patients are asymptomatic et al141 examined 42 patients requiring LSA revasculariza-
from this hemodynamic perturbation. However, some tion (5 transpositions, 37 bypasses), and only 1 patient
may suffer from subclavian steal syndrome and symp- (2.4%) developed a phrenic nerve palsy. Zamor et al128
tomatic vertebrobasilar insufficiency manifested as syn- described 23 patients who underwent LSA revasculariza-
cope, diplopia, or vertigo. In one series, upper extremity tion (21 transpositions, 2 bypasses) before TEVAR and had
ischemia occurred 12% to 20% of the time after LSA 2 (8.7%) occurrences of vocal cord paralysis, one of which
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resolved spontaneously. Wound complications, such as revascularization be individualized and addressed on

hematoma, lymphatic leak, and dissection, have also the basis of the patient’s anatomy and urgency of the
been reported.148 A series of 101 LSA revascularizations procedure. Level of recommendation: Grade 2 (Weak),
had a relatively high rate of permanent nerve injuries Quality of Evidence: B (Moderate)
(9%) along with a 6% lymph leak rate, requiring dietary
modification alone.149 Despite these complications, the Renal protection strategies for TEVAR
series reported only a 2% ischemic stroke rate and 0% Acute kidney injury (AKI) occurring during hospitalization
SCI after TEVAR. or after surgery has one of the highest risks of predicting
Despite a net benefit of reduction in SCI and stroke,150 mortality, especially if the AKI progresses to dialysis. When
these complications certainly compromise the effective- AKI occurs after TEVAR (w10%-15%), it increases the OR of
ness of TEVAR. Off-label and emerging technologies offer death to almost 10 even without a need for dialysis.158,159
the potential to reduce the complications of LSA surgical Many risk factors for AKI are associated with patients under-
revascularization. For well over a decade, various tech- going TEVAR (advanced age, chronic renal failure, diabetes,
niques have been described for retrograde in situ graft congestive heart failure, exposure to injectable contrast
fenestration and stenting, in which the TEVAR graft is dye, blood loss, major surgery) and possibly embolic injury
punctured with a needle or laser and dilated and a from endovascular manipulation within the aorta.
covered stent is inserted to bridge from the fenestration Importantly, contrast-induced nephropathy is the third
to the LSA,151-153 although the impact of these techniques leading cause of AKI in hospitalized patients. Although it
on the durability of the graft is unknown. Chimney or is plagued with inconsistent definitions in the literature,
double-barrel stents have also been described, which its incidence varies between 5% and 25%. Factors consis-
involve deployment of a covered stent in the LSA concom- tently shown to increase risk for contrast-induced ne-
itantly with a thoracic stent graft, preserving flow into the phropathy include age, diabetes, previous renal disease,
LSA.154,155 More recently, TEVAR grafts with a branch for and escalating doses of contrast material.159-161
the LSA have been developed and are actively being eval- Strategies reported to prevent contrast-induced ne-
uated in clinical trials.156,157 Industry-sponsored trials of phropathy are also marred by inconsistent reporting
fenestrated and branched distal aortic arch endografts standards and patient risk factors.160,161 These include
as well as multiple case reports of homemade or use of IVUS, minimizing the amount of contrast material
physician-modified endografts will likely change the used during the operation, prehydration with normal sa-
approach to revascularization of the LSA in the future. line (effectively increasing the volume of distribution of
Recommendation 19: For elective TEVAR of a TAA intravascular contrast material), and use of nonionic,
where coverage of the LSA is necessary for adequate iso-osmolar contrast agents.162,163 Research on pretreat-
stent graft seal, we suggest preoperative or concomitant ment with statins is evolving.164
LSA revascularization. Level of recommendation: Grade Recommendation 22: We recommend preprocedural
1 (Strong), Quality of Evidence: B (Moderate) TEVAR planning to include sizing and landing sites
Recommendation 20: For patients in whom the anat- before the case to minimize procedural contrast material
omy to be treated compromises perfusion to vital struc- use. If available, intraoperative CTA overlay technology
tures, we recommend LSA revascularization. Level of and IVUS should be used to minimize use of contrast
recommendation: Grade 1 (Strong), Quality of Evi- material. Level of recommendation: Grade 1 (Strong),
dence: B (Moderate) Quality of Evidence: B (Moderate)
Examples of these circumstances include the following: Recommendation 23: We recommend nonionic, hypo-
osmolar contrast material with attempts at minimizing
Presence of a patent LIMA to coronary artery bypass graft intra-arterial contrast agent use, especially in patients at
Termination of the left vertebral artery into the posterior high risk for contrast-induced nephropathy. Level of
inferior cerebellar artery
recommendation: Grade 1 (Strong), Quality of Evi-
Absent, atretic, or occluded right vertebral artery
dence: B (Moderate)
Patent left arm arteriovenous shunt for dialysis
Prior infrarenal aortic operation or EVAR with previously Recommendation 24: Depending on the patient’s
ligated or covered lumbar and middle sacral arteries corporal density and the capacity of the X-ray equipment
Planned extensive coverage ($15 cm) of the DTA available, we suggest diluting contrast material in the po-
Hypogastric artery occlusion or significant occlusive wer injector when possible (typically to 50% or 70%). Ad-
disease justments in injection volume and time (faster injection
Presence of aneurysm disease in the young patient, for of smaller doses) can usually compensate when addi-
whom future therapy involving the distal thoracic aorta tional visibility is required. Level of recommendation:
may be necessary Grade 2 (Weak), Quality of Evidence: C (Low)
Recommendation 21: For patients with acute thoracic Recommendation 25: We suggest the use of on-table
emergencies, for whom TEVAR is required urgently and mapping software options on fixed-imaging X-ray sys-
coverage of the LSA is necessary, it is suggested that tems, such as roadmapping and CT fusion or overlay
72S Upchurch et al Journal of Vascular Surgery
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reference, to aid in locating target landing sites and to from the SMA (92% and 77%, respectively). In addition,
minimize need for repeated injections. If available, CT flow from the left and right gastric arteries to the hepatic
overlay capability is extremely useful, especially in cases arteries has been documented.169 Examples of CTA-
in which location and cannulation of branches will be relevant findings that are important to note if CA
needed. Level of recommendation: Grade 2 (Weak), coverage is planned include significant stenosis of the
Quality of Evidence: B (Moderate) SMA, occluded inferior mesenteric artery, large post-
stenotic dilation of the CA, and inability to visualize the
Implementation remark pancreaticoduodenal or dorsal pancreatic branches.
In high-risk patients, placing and leaving wires, cathe- CTA alone may predict ischemia after CA coverage and
ters, or sheaths in aortic branches can mark the location the need for CA revascularization through open (tradi-
of target branches and minimize the need for repeated tional open surgical management) or endovascular inter-
contrast angiography. A marker catheter may be ventions (such as parallel [“snorkel”] stents or
inserted through a small-diameter left brachial artery fenestrations, given appropriate investigational device
sheath, for example, to mark the location of the LSA, or exemption and local experience). However, CTA does
a wire or catheter placed in the CA to mark its location not demonstrate dynamic flow and has been proved to
regardless of aortic or thoracic motion. This strategy be incorrect as a single imaging modality in predicting
can also allow bailout techniques in case of branch safe coverage of the CA after TEVAR by some
coverage. authors.170,171
Recommendation 26: To decrease the risk of athe- If CA coverage occurs without revascularization, a high
roembolization, we recommend minimizing intra-aortic degree of suspicion for ischemic complications should
wire, catheter, and endograft manipulation in the aortic be maintained postoperatively. Furthermore, ischemia
arch and at or above the visceral/renal arteries, especially symptoms can range from mild reversible abdominal
in patients with significant aortic atheromatous disease pain to mild liver enzyme elevation to lethal ischemic
or thrombus. Level of recommendation: Grade 1 injury of the foregut, spleen, or liver. Balloon occlusion
(Strong), Quality of Evidence: B (Moderate) has been reported by some in a small number of cases
Recommendation 27: We recommend minimizing the (n ¼ 5 each) to determine suitability for CA coverage,
dwelling time of large or occlusive femoral artery sheaths with unclear sensitivity and specificity.172 Thus, although
to decrease the risk of spinal cord ischemia and lower ex- it is reasonable in cases in which the results from mesen-
tremity ischemia that can lead to postoperative teric angiography are equivocal, no strong recommenda-
compartment syndrome or rhabdomyolysis. In cases in tion can be made.
which a large sheath must be left in place for a pro- The largest series of CA coverage included only 31 cases.
longed time, it can be withdrawn into the external iliac The protocol was to evaluate CTA for collaterals and, if ab-
artery to allow antegrade flow into the ipsilateral internal sent, to perform SMA angiography to evaluate for retro-
iliac artery. Meticulous postoperative vigilance to detect grade flow into the celiac branches. If absent, the CA was
inadequate lower extremity perfusion or compartment occluded with a balloon and the imaging repeated.
syndrome should be routine. Level of recommendation: Notably, the authors aggressively and pre-emptively
Grade 1 (Strong), Quality of Evidence: B (Moderate) treated SMA stenosis or cases in which partial SMA
coverage occurred during TEVAR (39% of cases) with
Recommendation for coverage or occlusion of the CA balloon-expandable stents. They documented one case
during TEVAR of lethal hepatic ischemia (despite subsequent open
TAA treated by TEVAR may require coverage of the CA bypass), one case of acalculous cholecystitis, and one
in about 4% to 6% of cases.89,165 This can add 1 to 2.5 cm case of sigmoid colon ischemia thought to be embolic.173
or more of aorta to obtain a distal seal. In addition, the CA Another study evaluated 18 TEVAR cases using only angi-
is stenotic in approximately 20% of patients, most of ography (no balloon occlusion) before CA coverage. Two
these being asymptomatic, presumably because of patients had documented mesenteric ischemia after CA
collateral mesenteric flow.166-168 Collaterals generally coverage. One patient had self-limited abdominal pain
arise from the superior mesenteric artery (SMA) and and two others had elevated white blood cell counts,
can be evaluated by selective SMA arteriography. Collat- also self-limited. No elevation in the liver or pancreatic en-
eral pathways can also be identified using high- zymes occurred after TEVAR.174,175 In another series, CA
resolution CTA reconstructions (ideally 1-mm cuts or coverage led to a delayed presentation of iatrogenic
smaller, 16-slice or greater), and the anatomic correla- chronic mesenteric ischemia despite only “encroaching”
tions have been well described.169 In 94 cases of celiac on the CA and a widely patent SMA.176
stenosis (13 with aberrant hepatic artery origins), 95% If the seal zone includes the CA orifice, an appropriately
had collateral flow from the pancreaticoduodenal and sized endograft alone should occlude the origin of the
75% from the dorsal pancreatic arteries. These were CA, obviating the need for embolization. If it is absolutely
similar in cases in which the hepatic arteries originated needed, CA embolization should be done carefully and
Journal of Vascular Surgery Upchurch et al 73S
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sparingly to avoid inadvertent extension of the embolic effective inner diameter of the delivery vessel, leading to
material into the common CA trunk and risking foregut the need for adjunctive methods of device delivery.
ischemia. In cases of TEVAR covering the CA, vigilant Several adjunctive measures can facilitate access in pa-
postoperative clinical examination and serial laboratory tients with small iliac vessels, including the use of more
studies should follow the early post-TEVAR period to proximal arteries as well as open or endovascular conduits.
detect and to address foregut and hepatic ischemia Femoral access. Traditional open femoral exposure
as early as possible to avoid morbid and lethal during TEVAR involves exposing the common femoral
complications. artery at the level of the inguinal ligament and establish-
Practice Statement: Although there are few high- ing sites for proximal and distal control. Unlike endovas-
quality data, we suggest dedicated SMA angiography cular AAA repair, in which medium- to large-diameter
through the SMA or CA with adequate imaging of the sheaths are placed in both groins, TEVAR can usually be
entire SMA and CA mesenteric collateral system to pre- accomplished through one femoral artery exposure with
cede TEVAR with intended or high risk for CA coverage. the other reserved for diagnostic imaging through a 5F or
(Ungraded good policy statement) 6F percutaneously placed sheath, if needed. When open
Recommendation 28: We recommend pre-emptive femoral artery exposure is performed, a transverse or
SMA stenting with a balloon-expandable stent in cases oblique skin incision is favored over the vertical approach
of >50% stenosis of the SMA in the following conditions: in the groin as it is associated with fewer wound com-
before or after CA coverage or encroachment, with plications. Wound complication rates (excluding hema-
TEVAR that is encroaching on the SMA origin, or in any tomas) after endovascular repair with a vertical incision
patient otherwise considered at high risk for post- are as high as 18%,178 whereas several studies with obli-
TEVAR mesenteric ischemia. Level of recommendation: que incisions have reported virtually no infectious wound
Grade 1 (Strong), Quality of Evidence: B (Moderate) complications.179,180
Recommendation 29: In anticipation of high risk for CA Percutaneous access of the common femoral artery for
territory ischemia (nonvisualization of CA collateral TEVAR is also a common approach to access and is
branches by CTA or dedicated SMA angiography), we increasing in frequency as surgeons become more
recommend open or endovascular revascularization of comfortable with it.181 A discussion of the pitfalls and
the CA before TEVAR. Level of recommendation: Grade merits of individual closure devices is beyond the scope
1 (Strong), Quality of Evidence: B (Moderate) of this document. However, several techniques have
Practice Statement: Maintain meticulous vigilance for been described for identification of the femoral artery,
signs and symptoms of mesenteric and hepatic ischemia including access through a small transverse incision182,183
early after CA coverage. (Ungraded good practice and ultrasound guidance,184,185 with reported success
statement) rates ranging from 92% to 96%. Ultrasound guidance
has become a standard component of percutaneous
Recommendation for access during TEVAR endovascular access at most institutions as it helps the
Importantly, access-related issues remain a common operator identify and avoid anatomic factors that could
source of morbidity after TEVAR, although these com- lead to failure of closure, such as coursing through the
plications are certainly decreasing with the increasing inguinal ligament or calcium on the anterior wall of the
lubricity and decreasing diameter of device delivery sys- artery. One study reported that the use of ultrasound
tems. In several early multicenter, industry-sponsored led to a 10-fold increase in successful percutaneous
trials, procedural failures ranged from 0.5% to 2% and EVAR procedures compared with those performed
were almost all secondary to the inability to advance without ultrasound (P ¼ .03).186
the device through inadequate iliac arterial sys- A meta-analysis performed of 3606 percutaneous arte-
tems.80,89,90 There has been an effort recently to rial access attempts for endovascular aortic repair
decrease the size of the sheaths and to improve the included 469 percutaneous TEVAR procedures. The over-
trackability of TEVAR delivery systems. Nonetheless, a all technical success rate was 94% per arterial access and
study of a lower profile device (sheath sizes 16F-20F) still the groin complication rate was 3.6%, with only 1.6% of
had a 2% failure to implant secondary to access patients requiring open repair of the groin.187 The most
issues.177 common complication was groin hematoma (1.8%), fol-
Depending on the size of the graft to be implanted, the lowed by pseudoaneurysm (0.7%). Factors that improved
outer diameter of delivery systems can be larger than 24F successful percutaneous access included ultrasound
with some devices. One French is approximately 1/3 mm; guidance (96.4% with ultrasound vs 93.5% without; P ¼
thus, a 24F outer diameter sheath is 8 mm in diameter. In .02) and a sheath size <20F (94.2% <20F vs 88.7%
the setting of normal vessels with little tortuosity, the $20F; P < .001).187 Other anatomic factors that have
vessel may stretch and allow delivery of a sheath that is been associated with improved success with a percuta-
larger than the actual inner diameter of the vessel. How- neous approach include a >1-cm segment of mid com-
ever, increasing tortuosity or calcification can reduce the mon femoral artery without anterior calcification,
74S Upchurch et al Journal of Vascular Surgery
January Supplement 2021

absence of severe scarring in the groin, native arterial ac- include tortuous iliac arteries, heavy calcification, and
cess (as opposed to access in graft material), and access small vessel size relative to the chosen device.
vessel diameter >5 mm.182,184,186,187 Percutaneous An open surgical iliac conduit is usually performed with
femoral access has a safety profile that is comparable a retroperitoneal exposure of the common iliac artery or
to that of open femoral access in anatomically appro- distal aorta through an oblique incision in the lower
priate patients, and both approaches are appropriate quadrant of the abdomen. The choice of common iliac
for TEVAR, even in the obese.188 artery vs the aorta should be based on CTA findings,
Recommendation 30: If an open approach for access is such as calcification and artery size. A 10-mm prosthetic
used, we recommend transverse or oblique incisions in conduit is best used because it will facilitate delivery of
performing open femoral access for TEVAR. Level of all currently available stent graft systems. The anasto-
recommendation: Grade 1 (Strong), Quality of Evi- mosis can be performed in an end-to-side or end-to-
dence: B (Moderate) end fashion. The conduit can be tunneled to the groin
Recommendation 31: We recommend using ultra- or brought subcutaneously through the abdomen so
sound guidance for percutaneous access to improve pro- that it creates an angle that allows straight delivery. At
cedural success and to decrease the rate of major the completion of the procedure, the conduit can be
complications. Level of recommendation: Grade 1 oversewn near the anastomosis. Alternatively, the distal
(Strong), Quality of Evidence: B (Moderate) end can be anastomosed to the common femoral artery
Recommendation 32: We recommend that percuta- to bypass an occluded or injured external iliac artery
neous access for TEVAR is safe and an acceptable alter- while also providing an easy conduit in the future if
native to open common femoral artery exposure if further interventions are necessary.191
certain anatomic criteria are met (eg, diameter of com- Direct puncture of the iliac artery and the aorta has also
mon femoral artery, lack of front wall calcium). Level of been described with avoidance of the need for a conduit.
recommendation: Grade 1 (Strong), Quality of Evi- Most often, these arteriotomies are closed primarily,
dence: B (Moderate) especially in the absence of extensive atherosclerotic
Iliac or aortic access. Multiple industry-sponsored trials occlusive disease.192
of TEVAR have shown that the sizes of the common and Recommendation 33: We recommend the use of iliac
external iliac arteries remain a barrier to device delivery in conduits or direct iliac or aortic punctures for TEVAR de-
some patients. Atherosclerotic occlusive disease can be livery to facilitate access in patients with small (relative to
treated with balloon angioplasty or use of the Dotter the chosen device), tortuous, or calcified iliac vessels. The
technique with serially larger balloons and dilators to decision to perform a conduit should be made in the
facilitate transfemoral delivery of a device, but it should preoperative setting, when possible. Level of recommen-
be performed carefully with low-pressure inflations dation: Grade 1 (Strong), Quality of Evidence: B
starting with a small balloon to avoid iliac rupture. (Moderate)
Data from the early Food and Drug Administration and Endoconduit. In an effort to avoid the potential
prospective company-sponsored investigational device increased morbidity and operative time associated with
exemption trials showed that iliac conduits were used a retroperitoneal exposure of the common iliac vessels or
in 15% to 21% of patients.80,90,189 Improvement in the pro- distal aorta, the use of angioplasty and stenting as an
file and size of delivery systems has decreased this num- endoconduit has been reported.192 In general, a 10-mm
ber significantly. An industry-sponsored trial of a TEVAR self-expanding covered stent graft is placed, but others
device with delivery systems that range from 16F to 20F have advocated placing an EVAR limb with at least a 12-
required an iliac conduit in only one (0.9%) patient.177 mm distal diameter as an endoconduit. This can then be
This low number was aided by strict exclusion criteria dilated with balloon angioplasty to an appropriate size.
that included iliac tortuosity, calcification, occlusive dis- Some authors have advocated for intentional rupture of
ease, and an inner wall diameter that was not adequate the iliac vessel within the stent grafted portion, given that
for the required sheath diameter.177 the vessel wall or atherosclerosis can continue to impede
A review of the National Surgical Quality Improvement device delivery even after endoconduit placement, espe-
Program database showed that conduits were more cially when there is bulky calcific disease.193
likely to be performed in women (15.7% female vs 5.8% In a retrospective series comparing open iliac conduit
male; P < .001), patients who are current smokers, and with endoconduit including 39 patients (23 open con-
patients with a previous coronary intervention.190 The de- duits, 16 endoconduits), the iliofemoral complication
cision to use an iliac conduit should be made during the rate was 20% for the entire cohort, but it was lower in
planning phase of the case as attempts to deliver a large the endoconduit group compared with the open
device through clearly inadequate iliac vessels can lead conduit (12.5% vs 26.1%). This was not statistically
to prolonged operative times and increase the risk of different secondary to small numbers of patients.194
hemorrhage and death secondary to iliac disruption. Other published experiences with this technique include
The anatomic factors that increase the need for conduits small cohorts of patients.195-197
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Recommendation 34: We suggest that endoconduits with a significant decrease in mortality from 45% in
to facilitate access for TEVAR are an acceptable alterna- open repair to 24% with TEVAR (P < .001).202 It is likely
tive to an open iliac conduit in some cases, but few that there is an early survival advantage to treating
data comparing them with an iliac conduit or long- ruptured DTA with TEVAR over open repair.
term data describing their outcomes over time are avail- There appear to be advantages to TEVAR over open
able. Level of recommendation: Grade 2 (Weak), Qual- repair of the DTA beyond survival. A meta-analysis
ity of Evidence: C (Low) comparing 224 patients from 28 articles showed a signif-
Carotid-axillary access. Use of the carotid and axillary icantly lower incidence of perioperative myocardial
arteries to deliver and to deploy thoracic stent grafts infarction (11% vs 3.1%; P < .05) compared with open
has been described,198 but these cases have been repair.203 In addition, a comparison of 161 patients from
reserved for extreme situations in which access cannot 7 hospitals during a 15-year period showed a lower inci-
be obtained from the lower extremities because of iliac dence of the composite end point of stroke, paraplegia,
or distal aortic occlusion. An approach to the DTA from and death in the TEVAR cohort compared with open
the arch vessels means that the stent graft will be repair (36.2% vs 21.7%; P < .05), but no difference was
deployed in an inverted fashion (unless predeployed and seen in the individual outcomes because of small
reinserted into the sheath, which would be an off-label numbers.204 Long-term outcomes have been reasonable
use of the device) and may be associated with an after TEVAR for ruptured DTA. A review of 21 patients
increased risk of neurologic complications due to the treated with TEVAR with a median follow-up of
wires and sheaths crossing the arch of the aorta. >5 years reported a late mortality of 52% with only one
More commonly, the brachial or axillary arteries are known aorta-related death.205
used to facilitate access from below by the so-called Most of the large series evaluating TEVAR for ruptured
body floss technique with a brachiofemoral or axillofe- DTA are from administrative databases, such as Medicare
moral wire, in which a wire is passed from the right and the National Inpatient Sample, and lack the
brachial or axillary artery and brought out the ipsilateral anatomic granularity that would allow meaningful com-
groin, typically by snaring the wire. With tension on parison of the cohort of patients undergoing each pro-
both ends, this technique can allow delivery of a stiff de- cedure (open TAA repair vs TEVAR). In addition, it is
vice through a tortuous and otherwise impassable aorta. difficult to determine the state of the patient at the
Care should be taken not to injure the origins of the bra- time of presentation as it is possible that one approach
chiocephalic vessels with the stiff wire passing through is favored in stable patients and another is used when
them. A long sheath (typically 5F or 6F) should be used a patient presents in extremis. Within these limitations,
to protect these vessels, and it can be used to cover the it appears that TEVAR for ruptured DTA is associated
tip of the delivery system on the stent graft and to facil- with improved survival and lower morbidity compared
itate delivery using a “push-pull” technique. with open repair.5
Practice Statement: Brachiocephalic access for TEVAR Recommendation 35: We recommend TEVAR over
device delivery may be acceptable in situations in which open repair for the treatment of ruptured DTA when it
transfemoral or iliac access is not available. However, is anatomically feasible. Level of recommendation:
more data are required to determine whether carotid- Grade 1 (Strong), Quality of Evidence: B (Moderate)
axillary artery access for delivery of a thoracic endograft
is associated with increased complications. (Ungraded SURVEILLANCE AFTER TEVAR
good practice statement) Surveillance after TEVAR is critical to identify endoleaks
after initial placement and to evaluate whether long-
Recommendations for treatment of symptomatic and term complications appear, such as migration, aneurysm
ruptured TAAs expansion despite no evidence of endoleak (type V endo-
Early mortality after open repair of ruptured DTA is high leak, so-called endotension), new endoleaks, device fail-
as evidenced by a Swedish study from the pre- ure (fracture, migration, component separation),
endovascular era that reported an in-hospital mortality stenosis, or occlusion. In addition, long-term evaluation
approaching 100%.199 The results with TEVAR have may detect signs of graft infection. The most often re-
been much more promising. A multicenter trial of acute ported protocol after TEVAR for aneurysm surveillance
aortic catastrophes showed a mortality of 15% in the is clinical examination and CT scans at 1 month,
ruptured arm.200 This compared favorably with the re- 6 months, and yearly thereafter.206,207 When TEVAR is
sults of open repair from the National Inpatient Sample placed for emergent indications, earlier evaluation either
database, which had an early mortality of 45%.201 Indeed, during hospitalization or within 1 week of placement
a review of the Medicare database from 2004 to 2007 may be warranted.208
showed that the percentage of ruptured DTA patients Difficulties in establishing surveillance protocols
who were treated with TEVAR increased from 17% in include variability in reporting of institutional protocols
2004 to 49% in 2007 (a total of 1033 patients treated), as well as reported rates of reintervention vs reporting
76S Upchurch et al Journal of Vascular Surgery
January Supplement 2021

of new findings in the surveillance protocols. Low reinter- Recommendation 36: We recommend contrast-
vention rates could imply the absence of significant find- enhanced CT scanning at 1 month and 12 months after
ings on surveillance imaging or a lack of intervention TEVAR and then yearly for life, with consideration of
despite the presence of new findings. Conversely, high more frequent imaging if an endoleak or other abnor-
reported reintervention rates could reflect either a high mality of concern is detected at 1 month. Level of recom-
rate of significant findings or simply a more aggressive mendation: Grade 1 (Strong), Quality of Evidence: B
approach to the findings treated conservatively at other (Moderate)
institutions. Recent evidence also shows that TEVAR
Implementation remarks about surveillance.
surveillance may be best tailored to the indication
for the TEVAR as certain pathologic processes may 1. In cases in which the 1-month CT scan demonstrates
warrant more frequent surveillance. A publication by morphologic endograft concerns (eg, “bird beaking,”
Meena et al209 evaluated 203 patients treated with infolding of endograft), endoleaks, or evidence of sac
TEVAR with follow-up CT scans and demonstrated growth and in high-risk patients (eg, those treated
aorta-related complications in 35% of patients, with sac for PAU or ruptured aortic aneurysms), repeated CTA
expansion accounting for 77% of these. with arterial and delayed phase imaging is recom-
Whereas long-term outcomes are beginning to be re- mended within 6 months.
2. In cases at low risk for expansion, such as those with a
ported, patients undergoing TEVAR for DTA aneurysm
shrinking aneurysm sac and >3 years of stability, non-
with straightforward anatomy and who fit within the de-
contrast-enhanced CT of the chest may be used to
vice’s instructions for use criteria rarely require late rein- follow aneurysm sac size and component stability.
tervention. In a series of 82 patients treated for TAA, 3. We can recommend neither eliminating TEVAR sur-
only 11% required reintervention at 60 months of veillance nor extending it further than annually,
follow-up.206 Indications for reintervention were type I given the lack of long-term evidence of safety and
endoleaks in about 7% and infection and type III endo- because of evidence of aneurysm growth and new
leaks in 1% each. No secondary intervention was per- endoleaks reported, despite a previously sealed
formed for aneurysm expansion or endograft collapse.206 aneurysm.
In contrast, 63 consecutive patients treated in Essen,
Germany, with TEVAR for PAU were followed up for a SPECIAL TAA CONSIDERATIONS
mean of 46 months. In this experience, 19% required Guidelines for hospital privileges have been established
reintervention for late endoleaks (6.3%), with the for TEVAR by the SVS.216 Calligaro et al217 suggested that
remainder requiring reintervention secondary to disease the requirements for TEVAR include full basic privileges
progression.210 A review of the outcomes captured in the with either 10 TEVARs within the last 2 years or less
Hospital Episode Statistics database in England revealed than this minimum for surgeons with a robust EVAR
that 6% of patients treated for intact aortic aneurysms experience, defined as 25 EVARs with 12 as the primary
required reintervention within 30 days after TEVAR.211 operator. Trainees should also be able to manage com-
The average time to any reintervention was 28 months. plex aortic patients as well as to perform adjunctive pro-
In contrast to those treated for intact TAA, 33% of pa- cedures, including iliac conduits and carotid-subclavian
tients treated with TEVAR for ruptured aneurysms will bypass grafting.
require additional intervention at 3 years.211 The relationship between volume and outcomes has
Concern for long-term, cumulative radiation exposure been explored for TEVAR,218-220 and the data supporting
has been growing, especially when TEVAR is performed or refuting such a relationship are poor, mainly because
in younger patients. Patients treated with TEVAR for these studies are typically underpowered and the data
intact aneurysms with favorable imaging findings by are heterogeneous, including EVAR and TEVAR, or
CTA at 1 month and 6 months are unlikely to have any TEVAR when used to treat multiple pathologic processes
complication in their lifetime that will need reinterven- (ie, aneurysm and dissection). One study using the Medi-
tion.212 Given the good outcomes exemplified in the care claims database from 1999 to 2007 documented a
two scenarios described before, it is not surprising that mortality rate for TEVAR in low-volume centers of 9%
delayed follow-up imaging (>1.5 years) has been shown to 10%, whereas mortality was 7% in high-volume TEVAR
to be relatively safe in midterm studies.213 However, there centers. Despite these gross mortality differences, a
is an absence of long-term data supporting this multivariable model for mortality failed to show volume
approach. In addition, late stent graft collapse, infection, as a predictor (P ¼ .328).218 A second study using Medi-
and endograft disruption can occur,214 and late conver- care Provider and Analysis Review data also found no as-
sion to open repair occurs at an average of 5 years and sociation between TEVAR volume and mortality.219
up to 98 months after initial implantation, suggesting Finally, a study using a Medicare Provider and Analysis
that patients undergoing TEVAR should be observed Review data set in 10,000 patients undergoing TEVAR
for life.101,215 found no clear relationship between hospital volume
Journal of Vascular Surgery Upchurch et al 77S
Volume 73, Number 1S

effect and survival. However, these same practitioners of the Society for Vascular Surgery. J Vasc Surg 2011;53:
suggested that using a mixed effects Cox model demon- 187-92.
8. Oladokun D, Patterson B, Sobocinski J, Karthikesalingam A,
strated an “independent hospital effect” associated with
Loftus I, Thompson M, et al. Systematic review of the
certain hospitals, with a death 50% of what occurred at growth rates and influencing factors in thoracic aortic an-
other hospitals.220 These data suggest that at present, eurysms. Eur J Vasc Endovasc Surg 2016;51:674-81.
no clear conclusion can be drawn between hospital vol- 9. Centers for Disease Control and Prevention. CDC WONDER.
ume and outcomes after TEVAR. Importantly, even fewer Underlying cause of death 1999-2016. Available at: https://
wonder.cdc.gov/controller/datarequest/D76;jsessionid¼0B2
data are available to examine the role of individual clini-
C1F1224200E7218A57C9E4FF682AF. Accessed February 11,
cian TEVAR volume and outcomes. 2018.
10. Bickerstaff LK, Pairolero PC, Hollier LH, Melton LJ, Van
Peenen HJ, Cherry KJ, et al. Thoracic aortic aneurysms: a
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comparing open and endovascular DTA repair directly improved outcomes reported in a nationwide population-
based study of more than 14 000 cases from 1987 to
and probably never will be, consensus documents, large
2002. Circulation 2006;114:2611-8.
administrative data sets, and meta-analyses have 12. LaRoy LL, Cormier P, Matalon T, Patel S, Turner D, Silver B.
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