Thoracic Endovascular Aortic Repair (TEVAR) for the treatment of aortic diseases: a position statement from the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

Abstract

Thoracic endovascular aortic repair (TEVAR) is an emerging treatment modality, which has been rapidly embraced by clinicians treating thoracic aortic disease.1–4 Fundamentally, it is a far less invasive approach than open surgery and its availability and relative ease of application has changed and extended management options in thoracic aortic disease, including in those patients deemed unfit or unsuitable for open surgery. In the operating room, this requires considerable perceptual, cognitive and psychomotor demands on the operators. The dramatic expansion of TEVAR activity has necessarily prompted a requirement to systematically consider the indications, appropriateness, limitations and delivery of this treatment, which has been adopted by many specialties including cardiologists, cardiovascular surgeons, radiologists and vascular surgeons.5 Our task has been to generate a multidisciplinary position statement that supports and advises all clinicians utilizing this technological advance. This document focuses on the main diagnoses—thoracic aortic aneurysm (TAA), thoracic aortic dissection (TAD) of the descending aorta (type B according to the Stanford classification) and thoracic aortic injury (TAI)—indications and applicability of TEVAR and includes information regarding its limitations and complications. It acts as a position statement for both societies that reflects current understanding of thoracic aortic endovascular therapy. Symptoms in patients with TAA and chronic dissection are rare and non-specific.6,7 New onset of hoarseness or dysphagia may suggest a developing aneurysm in the distal aortic arch and proximal descending aorta. Most asymptomatic cases are discovered incidentally, while symptomatic patients have usually developed complications. Even in patients with acute aortic syndromes, chest pain, back pain and signs of malperfusion are often misinterpreted due to lack of awareness. In cases of clinical suspicion, a computed tomography (CT)-angiography is the diagnostic modality of first choice. Patient selection should be performed on an individual basis according to anatomy, pathology, comorbidity and anticipated durability of any repair, using a multidisciplinary approach, ideally in an aortic centre. This concept offers the widest available opinion, an appropriate range of technical options and adequate infrastructure for endovascular therapy of thoracic aortic disease. The involvement of different specialties allows combining the best experience and expertise in medical, interventional and surgical therapy for tailoring an optimal treatment strategy for the individual patient. CT angiography (CTA) is the method of choice for diagnosis and planning treatment.8 Magnetic resonance imaging (MRI) is not widely used in the acute setting, but may be useful in chronic disease and during follow-up.9 Conventional angiography is no longer recommended as a routine diagnostic procedure. Positron emission tomography in combination with CTA may be used as an adjunct in specific situations (detection of signs of inflammation) but is not recommended for routine use.10,11 High-quality imaging and appropriate facilities for open surgery during the endovascular procedure are of the utmost importance. Purpose-built, hybrid operating and imaging suites appear to be the optimal solution.12 Transoesophageal echocardiography (TEE) is recommended as an adjunctive intraoperative imaging technique in complex aortic pathologies such as aortic dissection.13–15 Intravascular ultrasound and phased-array intracardiac ultrasound could be useful as well in cases of dissection.16,17 CTA prior to discharge is advised to delineate complications undetected during the initial endovascular procedure and to form a reference for follow-up studies. To avoid radiation MRI may be more widely used in the future,8 but it lacks the visualization of metallic stent struts and is not compatible with stainless steel endografts.18 To date, no TEVAR-specific risk stratification tool is available. Clearly, an individual risk stratification tool is required to predict endovascular outcomes and it will be the task of such working groups to establish a suitable tool in the near future. Until such risk stratification tools are available, individual patient's decisions will be made on the traditional basis of risk–benefit analysis.19 It is recommended that a transthoracic echocardiogram be performed as part of the diagnostic work-up in the elective setting in order to exclude valvular and structural heart disease. Further imaging should include a duplex ultrasound of the supraaortic vessels. A stress test to exclude coronary artery disease is not necessary in asymptomatic patients.20,21 Cardiac catheterization is suggested in patients with proven signs and symptoms of ischaemia or suspicion of coronary artery disease. A sufficient proximal and distal landing zone of at least 2 cm is necessary for the safe deployment and durable fixation of TEVAR