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Open vs Endovascular Repair of Descending Thoracic Aneurysms: Analysis of Outcomes

Published:November 22, 2022DOI:https://doi.org/10.1053/j.jvca.2022.11.020
      This manuscript examines the literature regarding the evolution, indications, mid- and long-term outcomes, and anesthetic management of thoracic endovascular aortic repairs (TEVAR) of the descending thoracic aorta (DTA). The FDA approval of TEVAR in 2005 has revolutionized repair of the DTA. Rupture of any of the six zones of the thoracic aorta is a devastating event associated with a high rate of morbidity and mortality.1-3 The thoracic aorta is divided anatomically into six zones based on Ishimaru's classification (see Figure 1): Zone 0 includes the ascending aorta to the innominate artery; Zone 1 from the innominate artery to the left common carotid artery; Zone 2 from the left common carotid artery to the left subclavian artery (LSA); Zone 3 from the LSA to 2 centimeters distal to the LSA; Zone 4 from Zone 3 to mid-descending thoracic aorta (∼T6); and Zone 5 extends to the celiac artery. Aneurysms involving the thoracic aorta are described using the modified Crawford classification system (see Figure 2): Extent 1 arises from the left subclavian artery to the renal arteries; Extent 2 arises from the left subclavian artery to the aortic bifurcation; Extent 3 arises from the sixth intercostal space to the aortic bifurcation; Extent 4 involves only the abdominal aorta; and Extent 5 arises from the sixth intercostal space to the renal arteries.4 Dissections involving the thoracic aorta have historically been described using one of two schemata: the DeBakey or Stanford classification systems. DeBakey Type I dissections extend from the ascending to the DTA, Type II is limited to the ascending aorta, Type IIIa is distal to the left subclavian artery and involves only the DTA, and Type IIIb is distal to the left subclavian artery and extending into the abdominal aorta. The more widely adopted Stanford classification system simplifies the DeBakey system and is based on whether the ascending aorta is affected. Dissections arising proximal to the left subclavian artery are classified as Stanford A (DeBakey Type I/II) and distal to the left subclavian artery are classified as Stanford B dissections (DeBakey Type III) (see Figure 2). In 2020, the Society for Vascular Surgery (SVS) and Society for Thoracic Surgeons (STS) published a new classification system for describing Stanford B (DeBakey III) aortic dissections using subscripts and zone numbers to describe entry tear location, and proximal and distal extent of dissection.5 This manuscript will focus on the DTA (Stanford Type B, DeBakey Type IIIa) distal to the left subclavian artery and proximal to the celiac artery.
      Figure 1
      Figure 1Zones of attachment
      Fillinger MF, Greenberg RK, McKinsey JF, Chaikof EL. Reporting standards for thoracic endovascular aortic repair (TEVAR). J Vasc Surg. 2010;52(4):1022-33.
      Figure 2
      Figure 2Classification of aortic dissection and aneurysm
      Anatomical classification of aortic dissection. Aortic dissection described by the DeBakey and Stanford classifications. From Nienaber & Clough, 2015 ().
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