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)

Perspective:

The following are 15 points to remember about this position statement:

1. Thoracic endovascular aortic repair (TEVAR) is an emerging treatment modality, which has been rapidly embraced by clinicians treating thoracic aortic disease.

2. The dramatic expansion of TEVAR activity has 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.

3. 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 center.

4. 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.

5. CT angiography (CTA) is the method of choice for diagnosis and planning treatment. Conventional angiography is no longer recommended as a routine diagnostic procedure.

6. 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.

7. CTA prior to discharge is advised to delineate complications undetected during the initial endovascular procedure, and to form a reference for follow-up studies.

8. In asymptomatic thoracic aortic aneurysm (TAA) patients, TEVAR is indicated (by consensus) when the maximum diameter of the aneurysm exceeds 5.5 cm or if rapid expansion (>5 mm in 6 months) occurs.

9. A sufficient proximal and distal landing zone of at least 2 cm is necessary for the safe deployment and durable fixation of TEVAR.

10. TEVAR is the treatment modality of choice in complicated acute type B aortic dissections (TADs). The term ‘complicated’ means persisting or recurrent pain, uncontrolled hypertension despite full medication, early aortic expansion, malperfusion, and signs of rupture (hemothorax, increasing periaortic and mediastinal hematoma).

11. The only important types of endoleaks in TAD are type Ia (antegrade perfusion of the false lumen) and type II (perfusion of the false lumen via the overstented left subclavian artery). Retrograde flow from distal entry tears must not be considered as endoleaks.

12. Immediate endovascular treatment is indicated in patients with complete transsection of the aortic wall and free bleeding into the mediastinum or pseudocoarctation syndrome, whereas delayed treatment can be suggested when limited disruption of the aorta is present but media and adventitia are intact.

13. The main outcome parameters for TEVAR are survival and aortic-related survival. Other clinically significant outcome parameters would include rate of persisting or newly developing endoleakage, freedom from reintervention, or secondary surgical conversion.

14. Lifelong clinical and morphological surveillance is mandatory after TEVAR, as late treatment failure may develop even years after the initial treatment.

15. The foundation of specialized aortic centers with a dedicated interest in aortic diseases and providing the full range of diagnostic and treatment options is strongly recommended.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Vascular Medicine, Hypertension

Keywords: Treatment Failure, Hemothorax, Blood Vessel Prosthesis Implantation, Follow-Up Studies, Endovascular Procedures, Comorbidity, Thoracic Surgery, Hematoma, Treatment Outcome, Consensus, Radiology, Perfusion, Endoleak, Cerebral Angiography, Mediastinal Diseases, Subclavian Artery, Patient Selection, Cardiology, Vascular Malformations, Hypertension, Adventitia


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