Hinchliffe.
qxp 13/10/06 2:39 pm
Robert J Hinchliffe is Endovascular
Fellow at the Endovascular Centre,
Malmö University Hospital, Malmö,
Sweden. His research interests are
in endovascular aneurysm repair
and ruptured abdominal aortic
aneurysms, performing research at
the University of Nottingham under
the supervision of Professor B R
Hopkinson. Thereafter he undertook
higher surgical training in general
and vascular surgery in Nottingham
until his present appointment
commenced in January 2006. Dr
Hinchliffe qualified from the
University of Bristol, U.K. in 1996
and underwent training in general
surgery in Nottingham, becoming a
member of the Royal College of
Surgeons of England in 2000.
Krassi Ivancev is Head of the
Endovascular Centre at Malmo
University Hospital in Malmo,
Sweden. He is currently involved in
research concerning further
development in the endovascular
field using branched stent-grafts
and subintimal recanalisation.
During the years, however, he has
been employed at various hospitals
in Sweden and also held a limited
license both in Oregon and Hawaii,
USA. Professor Ivancev is a member
of several professional societies,
among others the Swedish Medical
Association, Cardiovascular and
Interventional Radiology Society of
Europe, the International Society of
Endovascular Specialists and the
European Society for Vascular
Surgery. Professor Ivancev has
published a large number of
articles in peer-reviewed magazines
and numerous book chapters. Krassi
Ivancev received his MD in 1975 in
Lund, Sweden. His PhD degree was
attained in 1989 in the field of
Diagnostic Radiology
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Endovascular Repair
Endovascular Repair of Thoracic Aor tic Aneur ysms
R o b e r t J H i n c h l i f f e and K r a s s i I v a n c e v
Randomised trials in the infra-renal abdominal aorta
have demonstrated endovascular is better than open
repair in preventing aneurysm-related death up to
four years post-operatively. Patients with thoracic
aneurysms potentially have even more to gain from
the endovascular technique. Mortality rates from
open thoracic aneurysm repair are three times higher
than the infra-renal aorta. Furthermore, a 10% major
morbidity rate means that many patients are simply
too frail to withstand open surgery. In contrast, the
latest reports from the large EURopean Cobalt Stent
With Antiproliferative for Restenosis (EUROSTAR)
trial and the United Kingdom Registry for
Endovascular Treatment of Aneurysms (RETA)
suggest the peri-operative mortality for elective repair
of degenerative aneurysms is 5%.1 Patients requiring
emergency procedures for acute symptomatic or
ruptured aneurysms may benefit the most from
endovascular repair. Outcome from open surgery is
poor, whereas survival following endovascular repair
appears somewhat better (17% peri-operative
mortality).2 With such clear benefits randomised trials
in the thoracic aorta are probably unnecessary.
Stent-grafts designed for the thoracic aorta have
many similarities with infra-renal devices. There are,
however, a number of important differences to
consider in the thoracic aorta.
The forces encountered in the thoracic aorta,
particularly the arch are significantly higher than in
the infra-renal abdominal aorta. This puts greater
strain on endovascular devices. Stent-grafts
incorporating longitudinal stiff wires and those
comprising sub-standard nitinol stents have been
found wanting. Stent fractures have resulted in
design modification and, in some cases, devices have
been withdrawn from the market.
In the infra-renal aorta, the net force on the stent-graft
tends to act distally. Successful stent-grafts require
1. Leurs LJ, Bell R, Degrieck Y, et al., “Endovascular treatment of thoracic aortic diseases: combined experience from the
EUROSTAR and United Kingdom Thoracic Endograft registries”, J Vasc Surg (2004);40: pp. 670-679.
2. Bell RE, Taylor PR, Aukett M, et al., “Results of urgent and emergency thoracic procedures treated by endoluminal repair”,
Eur J Vasc Endovasc Surg (2003);25: pp. 527-531.
a report by
Endovascular Centre, Malmö University Hospital
proximal fixation to prevent distal migration. In the
thoracic aorta the net forces on the stent-graft tend to
produce proximal migration at the distal landing zone.
Barbs orientated cranially on the distal component may
prevent proximal migration. Distal migration is a less
common phenomenon and the use of uncovered
proximal stents with hooks and barbs is unnecessary and
dangerous. Numerous centres have reported uncovered
proximal stents eroding through the aortic arch.
Large diameter stent-grafts required for the thoracic
aorta pose two main problems. First, they require
high-profile delivery systems necessitating larger
access vessels. A detailed pre-operative assessment of
the iliac artery morphology should be undertaken.
Patients with narrow or excessively calcified and
angulated iliac arteries require iliac conduits to
facilitate device introduction. Second, large-diameter
grafts are subject to greater forces. These forces
increase the difficulty of accurate deployment and
potentially reduce stent-graft durability.
Despite some early failures with first generation stent-
grafts in the early to mid 1990s, currently available
stent-grafts can be expected to achieve successful
primary aneurysm exclusion in at least 90% of patients.
Endovascular repair of thoracic aneurysms is
associated with a number of major complications.
However, the incidence of these complications is
significantly less than in open repair. Appreciation of
the risk factors and early recognition reduces the
incidence and severity of these complications.
Spinal cord ischaemia following endovascular repair
occurs in up to 5% of patients compared with 8–15%
following open repair. The use of cerebro-spinal
fluid (CSF) drainage has been shown to improve
outcome in those patients who develop symptomatic
ischaemia. The role of prophylactic CSF drainage
remains controversial. Stent-grafting of the low
INTERVENTIONAL CARDIOLOGY 2006
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Endovascular Repair of Thoracic Aor tic Aneur ysms

thoracic/supracoeliac aorta, occlusion of the left
subclavian artery, hypotension (ruptured aneurysm) and
previous aortic (thoracic or infra-renal) surgery are most
vulnerable to spinal cord ischaemia. In these high-risk
patients prophylactic CSF drainage may be justified.
Stroke rates following endovascular repair should be
less than 2%. They are invariably the result of
emboli from the aortic arch. Thoracic stent-grafting
should be performed on a systemically heparinised
patient and with a minimum of guidewire
manipulation in the arch.
Some questions remain about the long-term durability
of thoracic stent-grafts. Long-term data is currently
only available on stent-grafts that have been
superceded by superior designs. However, most
studies suggest the number of endoleaks and secondary
interventions have been reduced to an acceptable
level. During a mean follow-up of 14 months with the
latest generation of stent-graft, Greenberg reported a
secondary intervention rate of 15%.3 Reported
endoleak rates vary. Lee reviewed 13 series and found
the endoleak rate ranged from 0–30%.4 Differences in
aneurysm morphology, type of stent-graft, operator
experience and method and duration of follow-up are
likely to account for the variation. Importantly, the
majority of long-term problems including endoleak
can now be managed by further endovascular
intervention rather than resorting to open conversion.
An alternative endovascular method for dealing with
for proximal descending aneurysms is to push the stent-
graft further around the arch which involves covering
the left subclavian artery. This manoeuvre gains an extra
10mm or so (the distance from the left subclavian artery
origin to the left common carotid artery) of proximal
neck and helps to improve the conformity of the stent-
graft around the distal aortic arch. Occlusion of the left
subclavian artery can be performed with relative
impunity. The presence of a left internal mammary
coronary artery (LIMA) bypass graft, or a dominant left
vertebral artery are contra-indications. Young patients
may complain of claudication post-operatively.
Fenestrated and side-branch stent-graft technology has
been used in patients with complex abdominal aortic
aneurysm morphology to preserve side-branch
patency. A small number of cases have been performed
using the same technology in the arch. These
techniques are in their infancy and are technically
difficult propositions. Stent-grafts are not torqueable in
the thoracic aorta due to the distances involved and the
tortuosity of the intervening vessels. Further, the risks
of cerebral embolisation from guidewire manipulation
in the arch are significant.
Some authors have described an alternative, hybrid
approach to repair aneurysms adjacent or proximal to
the left subclavian artery. The procedures comprise
one or more supra-aortic bypass grafts followed by

Despite some early failures with first generation stent-grafts in

the early to mid 1990s, currently available stent-grafts can be
expected to achieve successful primary aneurysm exclusion
in at least 90% of patients.

Many of the complications arising in contemporary endovascular exclusion of the aneurysm.

series of thoracic endografting comprise patients with
proximal thoracic aneurysms (adjacent to the left
subclavian artery/arch). Current stent-graft designs,
which are stiff, make conformity to the tortuous aortic
arch difficult. Young patients, where the aorta is
narrow and the arch describes a tight arc, present a
particular problem. Although some stent-graft designs
possess great flexibility, none have flexibility in the
most proximal portion. The consequence is that stent-
grafts tend to protrude in to the aortic lumen like a
chimney. Stent-grafts so orientated are destined to fail.
Overall, development of stent-grafts for repair of
distal descending thoracic aneurysms may be viewed
as a success story with encouraging peri-operative
and mid-term results. Satisfactory endovascular
solutions to arch and proximal thoracic aneurysms
have so far remained elusive. Endovascular specialists
need to work with industry to produce stent-grafts
that conform to the curvature of the aortic arch and
prevent the high number of graft related
complications seen in that area. ■

3. Greenberg RK, O’Neill S, Walker E, et al., “Endovascular repair of thoracic aortic lesions with the Zenith TX1 and TX2
thoracic grafts: intermediate-term results”, J Vasc Surg (2005);41: pp. 589-596.
4. Lee JT, White RA, “Endografting for thoracic aneurysm has replaced the need for open surgery”, Greenhalgh RM (ed.),
Vascular and Endovascular Controversies (2003), London, BIBA Medical Ltd.

INTERVENTIONAL CARDIOLOGY 2006 59