Despite the promise of TEVAR, it must be emphasized that the procedure is technically complex and has significant perioperative mortality of up to 12.5%, as reported in one series examining thoracoabdominal aneurysm endograft repair [28]. Frequent intraoperative complications include damage of the target vessel and its branches, device malposition, and access problems. Significant perioperative complications abound, including stroke, persistent renal dysfunction, and paraplegia or paraparesis secondary to spinal cord ischemia. [7,29]. Because late endoleaks have been reported in 10% to 41% of cases, continuous surveillance imaging is necessary to gauge the need for reintervention [30]. Additional postoperative complications include progressive aneurysmal degeneration of the aorta as well as potentially life-threatening complications such as retrograde dissection [31]. A commonly cited disadvantage of TEVAR with respect to open repair is the high rate of reintervention. For example, a recent study demonstrated a 32% reintervention rate at 4.7 years after aortic dissection repair [32]. A caveat is that the presence of an existing endograft can reduce operative risk in subsequent procedures. In cases of distal aneurysmal degeneration in the setting of prior TEVAR for chronic type B dissection, the indwelling endograft can serve as the attachment point for a new aortic graft, thereby reducing the extent and risk associated with reintervention [33]. Open surgical repair remains the treatment of choice in cases of acute Stanford type A dissection. This is because of the myriad anatomic constraints imposed by the proximity to the coronary ostia, aortic root or valve, and brachiocephalic trunk [11]. Use of TEVAR in asymptomatic, uncomplicated, chronic Stanford type B dissection is also controversial, with mixed survival benefit results when comparing TEVAR with optimized medical therapy [34,35].
Thoracic Aortic Aneurysm or Dissection Treatment Planning and Follow Up. Despite the promise of TEVAR, it must be emphasized that the procedure is technically complex and has significant perioperative mortality of up to 12.5%, as reported in one series examining thoracoabdominal aneurysm endograft repair [28]. Frequent intraoperative complications include damage of the target vessel and its branches, device malposition, and access problems. Significant perioperative complications abound, including stroke, persistent renal dysfunction, and paraplegia or paraparesis secondary to spinal cord ischemia. [7,29]. Because late endoleaks have been reported in 10% to 41% of cases, continuous surveillance imaging is necessary to gauge the need for reintervention [30]. Additional postoperative complications include progressive aneurysmal degeneration of the aorta as well as potentially life-threatening complications such as retrograde dissection [31]. A commonly cited disadvantage of TEVAR with respect to open repair is the high rate of reintervention. For example, a recent study demonstrated a 32% reintervention rate at 4.7 years after aortic dissection repair [32]. A caveat is that the presence of an existing endograft can reduce operative risk in subsequent procedures. In cases of distal aneurysmal degeneration in the setting of prior TEVAR for chronic type B dissection, the indwelling endograft can serve as the attachment point for a new aortic graft, thereby reducing the extent and risk associated with reintervention [33]. Open surgical repair remains the treatment of choice in cases of acute Stanford type A dissection. This is because of the myriad anatomic constraints imposed by the proximity to the coronary ostia, aortic root or valve, and brachiocephalic trunk [11]. Use of TEVAR in asymptomatic, uncomplicated, chronic Stanford type B dissection is also controversial, with mixed survival benefit results when comparing TEVAR with optimized medical therapy [34,35].