December 22, 2008

The role of Anatomic factors in Predicting Success of Endovascular Repair of Thoracic Aortic Aneurysms

Jonathan N. Bowman, M.D., Sharif H. Ellozy, MD, Daniel Silverberg, MD, Victoria Teodorescu, MD, Honesto Poblete, MD, Michael L. Marin, MD, Peter L. Faries, MD.
Mount Sinai School of Medicine, New York, NY, USA.

Objective:
Variation in the anatomy of thoracic aortic aneurysms may impact the morbidity of endovascular repair. We evaluated the results of thoracic endovascular aneurysm repair (TEVAR) to determine what anatomic factors influenced the clinical outcomes.
Methods:
The pre-operative CT angiograms of 68 patients, who underwent TEVAR, were analyzed using the Aquarius workstation by TeraRecon. Using the 3-D reconstructed images the proximal and distal aortic neck, the thoracic aneurysm and the iliac arteries were measured for angulation, diameter, length, calcification and tortuosity (Figure 1). The calcification was defined as mild, moderate or severe based on percentage of wall calcium along the vessel length. Technical success, defined as successful deployment with no endoleak and clinical success, defined as freedom from endoleak at follow-up, were measured.
Results:
90% of our patients had immediate technical success. The device was unable to be deployed in 5 patients. 1 Gore graft and 4 Talent grafts were unable to be deployed due to aortic tortuosity inhibiting deployment or graft advancement. 2 patients had a primary endoleak; 1 type IV and 1 proximal type I. 82% of patients had clinical success at follow-up. The mean follow-up is 8 months with a range of 1-36 months. The significant predictors of deployment failure are listed below in Table 1.
Conclusions:
Pre-operative 3-D imaging may be useful in evaluating arterial anatomic factors that may affect the performance of TEVAR. Decreased distal aortic neck angulation (Figure 2) and increased iliac calcification correlate with an inability to deliver or successfully deploy the device.

Significant Predictors of Deployment Failure
	Distal Neck Angle	R Iliac Calcification^‡	L Iliac Calcification^‡
Success (63)	160° ± 12	Mild	Mild
Failure (5)	146° ± 13	Severe	Severe
Significance	P = 0.031*	P = 0.002**	P = 0.019**
* - Calculated from Students T-Test ** - Calculated from Mann-Whitney Test^‡ - Calculated From SVS reporting standards

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