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Anatomical Eligibility For Endovascular Repair Of Descending Thoracic Aortic Aneurysms

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Peter H. Lin, MD, Ruth L. Bush, MD, Wei Zhou, MD, Michael J. Reardon, MD, Alan B. Lumsden, MD.
Baylor College of Medicine, Houston, TX, USA.

Introduction: Endovascular repair of descending thoracic aortic aneurysm (DTAA) is associated with decreased morbidity and excellent early outcome. The aim of this study was to assess the anatomical eligibility for endovascular repair in patients with DTAAs using guidelines of a current clinical investigation.
Methods: Imaging studies of all patients who underwent open repair of DTAAs from July 1998 to June 2004 were reviewed. Patients with aneurysms involving the ascending or thoracoabdominal aorta were excluded. Anatomical features of each aneurysm and eligibility rates for endovascular repair using guidelines of a current clinical trial were analyzed.
Results: Among a total of 254 open DTAA repairs performed during the study period, suitable imaging studies were available in 180 patients (71%) which formed the basis of this analysis. Asymptomatic and symptomatic aneurysms occurred in 134 (74%) and 46 (26%) patients, respectively. Maximal DTAA diameters in symptomatic and asymptomatic groups were 65 +/- 13 mm and 61 +/- 11 mm (P=0.03), respectively. When comparing the proximal aortic neck distal to the subclavian artery, the symptomatic group was 3mm larger in diameter (39 +/- 6 mm versus 36 +/- 4, P=0.04) and 8 mm shorter in distance (14 +/- 9 versus 22 +/- 13, P=0.02) than the asymptomatic cohort. No significant difference was noted in the distal aortic neck morphology between the symptomatic and asymptomatic groups. Using anatomical criteria of a current clinical trial, 81% of patients (109/134) with symptomatic DTAAs would be eligible for DTAA endograft implantation compared to 78% of patients (36/46) patients in the asymptomatic group (NS). With planned subclavian artery exclusion, the eligibility rates in the asymptomatic and symptomatic groups would be increased to 88% (118/134) and 83% (38/46, P=0.03) respectively. Overall 87% of patients met the anatomical eligibility criteria. When comparing the symptomatic and asymptomatic DTAAs, the primary reason for anatomical ineligibility was an inadequate proximal neck length (12, 9% versus 4, 9%, NS), followed by large proximal neck diameter (5, 4% versus 4, 9%, P=0.04).
Conclusions: Eighty-seven percent of patients with DTAAs met the anatomical eligibility criteria for endovascular repair based on a current clinical trial guideline. Unfavorable proximal neck was the main exclusion reason for endovascular DTAA repair. With planned subclavian artery exclusion using an endograft, a greater proportion of asymptomatic patients would become eligible for endovascular repair compared to the symptomatic cohort.