Endovascular Repair of Thoracic and Abdominal Aortic Aneurysms / Dissections

1. Endovascular Repair of Thoracic and Abdominal Aortic
Aneurysms / Dissections

2. Review Article
INTRODUCTION
In the last two decade, there has been a considerable
advancement in the treatment of Abdominal and Thoracic
AorticAneurysms. For the past many years surgery was the
only treatment available for treating this condition, but it
carried a high mortality and morbidity. We even lost the
great Scientist Dr.Albert Einstein because of the rupture of
aortic aneurysm (Fig. 1). In the last decade, endovascular
techniques have developed for the treatment of aortic
aneurysms and in properly selected patients, the mid-term
resultswithendovasculartherapyareverygratifying. There
has been a significant decrease in the mortality and
morbidity.
ENDOVASCULAR REPAIR OF THORACICANDABDOMINALAORTIC
ANEURYSMS / DISSECTIONS
N N Khanna
Senior Consultant Interventional Cardiology & Vascular Interventions, Co-ordinator-Vascular Services & Advisor,
Apollo Group of Hospitals, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India.
Key words: Thoracic and abdominal aortic aneurysms.
In 1991 Dr. John Carlos. Parodi performed the first
endovascular repair of Abdominal Aortic Aneurysm
(AAA). Since then this technique has been refined and
successfully used in treating not only abdominal aortic
aneurysms but also aneurysms and dissections of Thoracic
Aorta. It is also been used successfully in traumatic
ruptures and ulcers of the aorta.
In this chapter, we briefly review of the endovascular
treatment of aortic aneurysms.
ANEURYSM OF THORACICAORTA
The incidence of thoracic aneurysm is 6-10.4 per
100,000 per year. In the last three decades, the global
incidence has doubled mainly because of increased
longevity of patients and improvement in diagnostic
techniques like CT scan and MRI. They are three times
more common in males as compared to females. The
average age of presentation is about 70 years. They occur
in ascending aorta in 45% cases, in descending thoracic
aorta in 35% cases and in aortic arch and a thoraco-
abdominal region in 10% cases. The risk of rupture
increasesifthediameterexceeds6cm(theriskofruptureis
20% per year). The main risk factors are: age ≥70 years,
male sex, hypertension, diabetes, dyslipidemia, and
smoking.
ETIOLOGY
Atherosclerosis
This is the most common cause of aortic aneurysms.
The atherosclerotic aneurysms are usually fusiform in
shape and are present in older people who have evidence of
multi-vascular atherosclerosis (Fig 2 a-e). They are often
associated withAbdominalAorticAneurysm.
A case of aneurysm of arch of aorta (a) with coronary
arterydisease(LADstenosis)andrightrenalarterystenosis
(b) treated by endoluminal stent grafting (c) and renal (d)
217 Apollo Medicine, Vol. 8, No. 3, September 2011
Fig 1. Albert Einstein

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Apollo Medicine, Vol. 8, No. 3, September 2011 218
(a) (b)
(c) (d) (e)
and coronary artery stenting (e) at Indraprastha Apollo
Hospital.
AORTIC DISSECTIONS
They occur in acute type B dissection or as a
complication of type a dissection. In these cases the wall of
aorta is circumferentially split in a spiral fashion creating a
true and a false channel. The outer false channel consists of
adventitia and a small portion of media. Aneurysm forms
when circulation continues inside this false channel. The
dissection usually occurs in the entire length of Thoracic
andAbdominalAortaandtheresultinganeurysmhasahigh
propensity for rupture (Fig 3).
(i) Trauma: Traumatic aneurysms are usually present at
the isthmus of aorta. They are common in young
individuals.
(ii) Connective Tissue Disorders: Marfans syndrome,
Ehlers-Danlos syndrome, Tuberculosis, Systemic
Fig 2. A case of aneurysm of arch of aorta (a) with coronary artery disease (LAD stenosis) and right renal artery stenosis (b)
treated by endoluminal stent grafting (c) and renal (d) and coronary artery stenting (e) at Indraprastha Apollo Hospital.
Fig 3 Acute type B dissection. Note the True (TC) and the
False Channel (FC)

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219 Apollo Medicine, Vol. 8, No. 3, September 2011
Lupus Erythromatosis etc are associated with aortic
aneurysms, commonly in thoracic aorta.
(iii) AutoimmuneArteritis-TakayasuArteritis,Behcet’s
syndrome,GiantCell Arteritis.
(iv) PseudoAneurysmaftersurgicalanastomosis(Fig 4a-
c).
(v) Penetrating ulcers and intramural haematomas.
Natural history of aneurysm of thoracic aorta
Thoracicaneurysmswhichare6cmindiameterorwhich
have increased by >5mm in 6 months have very high risk of
rupture in them, the actuarial 5 years survival is 20%. In
these patients the cause of death is aortic rupture. They
become symptomatic because of compression of adjacent
structures(dyspnoea,hoarsenessofvoiceanddysphagia)or
thrombo embolism to lower limb, GI tract, kidneys and
spinal cord. They may also rupture into the pleural cavity
causing massive haemothorax (which is usually fatal), or
into the adjacent bronchus or esophagus causing
haemoptysis or haematemesis.
Management
The mainstay of management is to lower the blood
pressure, and to follow the the aneurysm by CT scan or
USG. The aneurysm should be treated as soon as they start
posing a risk of rupture.The treatment should be either
surgical or endovascular repair.
Surgical repair
Thishasbeenthemainstayoftreatmentformanyyears.
The concept of surgery is to simply remove the diseased
aorta and to replace it with an interposition graft. However,
in practice this type of surgery carries a very high mortality
andmorbiditybecausethesepatientsareextremelysickand
have many co morbidities. Surgery involves exclusion of
(a) (b) (c)
Fig 4. (a)Alarge psuedoaneurysm of ascending aorta with erosion into right bronchus causing haemoptysis; (b) & (c) successfully
treated by endovascular technique using septal occluder device.
left lung and also leads to acute haemodynamic problems
because of aortic clamping leading to decreased circulation
tothekidneyandspinalcordwhichleadstorenalfailureand
paraplegia. Surgical mortality is 15%in elective cases and
50% in emergency cases. Death usually occurs because of
heart and lung failure. 15% of surgical patients require
prolonged ventilation and 20% go into the renal failure.
After surgery the 5 years actuarial survival is 60%.
Endovascular repair of thoracic aortic aneurysm
The experience from endovascular repair ofAbdominal
AorticAneurysm has been very good. It has many inherent
advantages and this technique can logistically be used in
treating thoracic aneurysm and dissection of thoracic aorta
also.
Case selection for endovascular repair
Proper case selection is the most important determinant
of success of endovascular repair.
The patient selection for endovascular repair must take
into account the risk attached because of the presence of co-
morbidities, the risk of spinal cord ischemia and the
anatomy of the aneurysm. CT scan with 3mm cuts is
essential for planning the procedure and selecting the
device.
Foradequateanchorageofthestentgraft,ideallengthof
theneckaboveandbelowtheaneurysmshouldbemorethan
20mm. If the proximal neck is short, the left subclavian
artery can be covered. The inferior neck should be at least
1cm above the coeliac trunk.
The diameter of the access vessels (Femoral / External
IliacArtery)isveryimportant. Thevesselshouldbeatleast
7.5mm–8mmindiameter.ThoracicStentGraftrequires20
– 24 french sheaths for introduction. Proper attention must
bepaidtothepresenceofiliac/aorticstenosis,calcification
and tortuosity.

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Apollo Medicine, Vol. 8, No. 3, September 2011 220
The diameter of the stent graft should be at least 15% -
20% more that the diameter of the normal aorta proximal
to the aneurysm. The length of the graft is usually 15 cm-
20 cm. It can be extended by overlapping with additional
stent grafts. The recommended overlap between the two
should be 2cm.
Technique of device implantation
The procedure is undertaken in the cardiac
catheterization suite with facilities of digital substraction
angiography (DSA) and road mapping. It is important to
fix landmarks after the control angiogram and not to move
the table during the procedure. The LAO view is usually
used to profile these aneurysm and the arch vessels.
Arterial access is gained by surgical exposure of the
femoral artery. Ideally, the common femoral artery should
be ≥8 mm in diameter. If the common femoral artery is
small, it is prudent to expose the external iliac artery by
extending the incision. Sometimes common iliac artery is
exposed by retroperitoneal approach and the graft conduit
is anastomosed to it for easy delivery of the stent graft.
After the femoral artery exposure, arterial puncture is
made and a 0.035" guide wire (super stiff amplatz guide
wire / Backup Mier wire) is introduced all the way up to
ascending aorta. The stent graft is then advanced on the
guide wire so that the covered portion of the stent is placed
at least 20 mm proximal to the origin of aneurysm/
dissection. Right brachial access is often very useful and
frequent angiograms can be done with the help of a 5 Fr
pigtail catheter introduced via right brachial artery for
accurate positioning of the stent graft The stent graft is
deployed by withdrawing the delivery sheath. After
deployment a tri-foil compliant balloon is used to dilate
the stent and remove any creases in the fabric. The success
of the procedure is assessed by a completion angiogram
and the balloon and the guide wire are then withdrawn.
The arteriotomy is surgically repaired and the patients are
discharged on the 3rd post operative day (Fig. 5).
For treating dissection of the Thoracic Aorta, the goal
of the treatment is just to seal the entry point of dissection
and to redirect blood flow from normal aortic segment to
true lumen. This leads to stagnation and eventually
clotting of the blood in the false lumen and over a period of
time the aneurysm shrinks in size. Peri operative Trans-
Esophageal Echocardiography (TEE) is of immense value
in assessing the success of the procedure.
Procedures helpful to facilitate the delivery of the
device
(i) Exposure of distal external iliac artery.
(ii) Sub-peritoneal iliac access. It allows for
implantation of the device in cases when the femoral
and external iliac arteries are of small diameter.
Many times a prosthetic graft is sewn on the external
iliac artery. This allows a straight and wide access of
the prosthesis into the aorta.
Fig 5 (a) Thoracic Aortic Aneurysm (TAA) before procedure (b) TAA after ZenithTX2 stent graft.
(a) (b)

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221 Apollo Medicine, Vol. 8, No. 3, September 2011
(iii) Femoral and brachial access: In this we have a
femoral access and a contra lateral brachial access
and a super stiff guide wire is passed from the
brachial artery into the descending thoracic aorta and
abdominal aorta and is snared out of the contra
lateral femoral artery. This straightens the axis of
implantation and facilitates the delivery of the
device.
Treatment of visceral ischemia in aortic
dissection
If the visceral vessels (renal, superior mesenteric, coelic
axis) are involved in the dissection and there is a preferential
flow of blood into the false lumen, severe ischemic
complications can occur. In such cases, fenestration of the
intimal flap by a trans-septal needle is done to restore blood
supply to visceral organs. Stents are sometimes placed at the
ostium of viscera arteries to reopen compression or to treat
the flow limiting intimal flaps at the ostium. Sometimes
fenestrated devices which are available can be used (Fig 6).
Adjunctive treatment
In case of dissection involving the subclavian artery or
the arch vessels surgical transposition of the neck arteries
to the ascending aorta is done to give adequate space for
the stent graft to be anchored in the arch of aorta.
In cases of severe paraplegia cerebro spinal fluid is
drained. This may allow faster recovery of the paraplegia.
Follow-up
After successful implantation of thoracic or abdominal
stent graft, periodic surveillance and follow-up is
essential. Six-monthly contrast enhanced CT scan with 3
mm cuts is essential (Fig. 4). The things to look for are:
• Endoleaks
• The diameter of aneurysm
• Remodeling of the aneurysm
• Migration of stent
• Kinking/fractures of struts
• Shrinkage of false lumen
Volumetric assessment measuring the volume of
aneurysmal sac is more reliable in following up these
aneurysms. A stable aneurysm does not mean that it is
essentially cured. It may still have a high tension
(endotension). Sometimes a special catheter based chip
sensor (EndosureTm wireless sensor) is left in the
aneurysm sac to measure the pressure within the sac by
remote control. (Fig 7).(a)
(b)
Fig 6. (a) Fenestrated graft for renal arteries (b) : A patient of
juxta-renal abdominal aortic aneurysm treated
successfully by fenestrated endoluminal stent graft. Fig 7 Endosure wireless AAA pressure sensors.

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If the aneurysmal sac is increasing in size, it means that
the tension within the aneurysm is high either because of
the endoleak or because of endotension. Secondary
procedures like placement of additional stent grafts to seal
type I endoleaks may be done. The feeders responsible for
Type II endoleaks should be closed by interventional
radiological techniques. In case we cannot seal these
endoleaks, we should resort to open surgical treatment.
Results of endovascular treatment of thoracic
aneurysms
The results of endovascular treatment of TAA are
shown in the following table (Table 1). The mean
actuarial survival of these patients is 85% over 18-24
months.
Abdominal aortic aneurysm
In 1991, John Carlos Parodi implanted the first
endoluminal stent graft to exclude Abdominal Aortic
Aneurysm (AAA). This technique has emerged as an
alternative to surgical treatment of AAA. Initial and mid-
term results of ELG (Endoluminal stent grafting) are very
encouraging.
Case selection for endovascular repair
The principles for case selection for endovascular
repair of Abdominal Aortic Aneurysm are the same to that
of the Thoracic Aneurysms. Following parameters are
essential for predicting the success of endovascular repair.
(i) Infra renal neck of > 2 cm
(ii) Angulation of the neck < 45º
(iii) Neck <30 mm in diameter
(iv) Fusiform aneurysm without history of rupture
(v) Minimal or no tortuosity of iliac arteries
(vi) Absence of aneurysmal iliac arteries
(vii) Femoral access vessel >7.5 mm
(viii)Absence of stenosis in iliac vessels
(ix) Absence of calcification and stenosis of aortic
bifurcation
(x) Healthy femoral vessels on both sides
(xi) Absence of stenosis of ≥2 mesenteric arteries
Endovascular repair
The technique of deployment of the stent graft for
abdominal aortic aneurysm is similar to that described for
ThoracicAneurysms. InAbdominal AorticAneurysm, we
need to have bilateral femoral cut-down as the device is
modular in design and is reconstructed inside the
aneurysmal abdominal aorta.
Essentially, these grafts consists of a nitinol self
expanding stent covered with fabric either on the inner
surface or the outer surface. The fabric is either Dacron
(polyethylene terephthalate Dacron) or PTFE (PolyTetra
Fluro Ethylene). In modular designs there is a main body
and an ipsilateral limb of the device and a contra lateral
limb which docks into the contra lateral gate of the main
device. Aorto Uni-iliac stent graft is used when the one of
the iliac arteries is extremely tortuous and calcified. Here
we have a tapered stent graft from the infra renal
abdominal aorta to one of the iliac arteries. The contra
lateral iliac artery is occluded endovascularly by
implanting an occluder. This is followed by a fem-fem
cross over graft to maintain a perfusion in the opposite
lower limb.
Table 1: Results of thoracic aortic aneurysms
Author (Year) Aortic stent- No Early Conversion Paraplegia Long-term
grafting TAA Mortality (%) (%) (%) survival (%)
Mitchell R. Dake M. 1999 103 103 9 4.8 2.9 73+5actuarial 2 yrs.
Greenberg R. 2000 25 25 20 12 12 NA
Buffolo E. 2002 191 61 10.4 9.8 0 87.4+29(actuarial)
Criado F. 2002 47 31 2.1 0 0 87.2 FU:18 mths
Heijmen R. Moll F.,2002 28 28 0 3.6 0 36.4 FU:18 mths
Herold U2002 34 7 2.9 0 0 91.2FU:18 mths
Najibi S. LumsdenA. 2002 19 19 5.3 5.3 0 94.712 M
Orend K. Sunder-Plassmann L. 2003 74 40 9.5 (30 days) 8 0 91.7FU:18 mths

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After arteriotomy 0.035" stiff guide wire is introduced
and parked in the ascending aorta. A 24 French device is
then advanced over this guide wire and taken above the
renal arteries. The bare flanks are opened above the renal
arteries and the device is positioned in such a way that the
covered portion of the stent graft starts just below the
lower renal artery. After this the sheath is withdrawn to
deliver the main body in abdominal aorta and ipsilateral
limb in the iliac artery. A guide wire is then passed from
the contra lateral femoral artery into the contra lateral gate
of the main device and parked into the ascending aorta.
The contra lateral limb of the device is then advanced over
this guide wire and parked in the main device in such a
way that we get an overlap of at least two segments. The
device is delivered by withdrawing the sheath. The stent
graft is post dilated by a complaint balloon, especially at
the proximal segment, the distal iliac segments and the
overlapped segment of contra lateral limb and the main
body. Completion angiogram is done to document
complete exclusion of the aneurysm and to look for
endoleaks. The guide wires are removed and the femoral
arteries are repaired and the skin is closed. The procedure
is done under epidural anesthesia (Fig 8).
COMPLICATIONS OF ENDOVASCULAR REPAIR
OF AORTIC ANEURYSM
Access complications
(a) Rupture of the femoral or iliac artery: can be
avoided by
(i) Proper selection of the case so that the devices are
introduced in large and suitable arteries.
(ii) Lubricating the device before insertion
(iii) Dilating any aorto iliac stenosis before
introducing the device
(b) Thrombosis of the femoral artery: can be avoided
proper anti-coagulation
Retroperitoneal haemorrhage: This usually occurs
because of rupture of iliac arteries or abdominal aorta
during manipulation of the device during final balloon
dilatation. It is life threatening and should be immediately
managed by temponading with a balloon and surgical
repair of the vessel or by placement of stent graft. The
Fig 8 (a) Infra-renal Abdominal Aortic Aneurysm AAA; (b) Successful endovascular repair.
(a) (b)

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Apollo Medicine, Vol. 8, No. 3, September 2011 224
anticoagulation should be immediately reversed by giving
IV protamine.
Embolism: Embolism can occur in renal, mesenteric or
femoral artery or in the arteries of the leg. It is important to
identify this complication. It is treated by embolectomy or
thrombolysis. Some of these patients may still land up
with trash foot, renal failure or gut infarctions.
Endoleaks
Endoleaks represent persistent residual flow into the
aneurysmal sac after endovascular stent graft placement.
It can be present immediately after the procedure
(primary endoleaks) or occur as late complication
(secondary endoleaks). The incidence varies from 10% –
30% in the literature and in many cases it seems to regress
spontaneously. Endoleak is the most important
complication of endovascular repair. If left untreated it
leads to expansion and rupture of the aneurysm. The
endoleaks are of the following 4 types.
Type-I Endoleak: It is a leak at the proximal or distal
attachment point of the stent graft. This is the commonest
type of endoleaks and is treated by putting in additional
covered stents. This can be easily avoided by proper
selection of the patient and the device and by making right
assessment of the anatomy and size of aortic neck and iliac
vessels.
Type-II Endoleak: This is back-filling of the aneurysm
from inferior mesenteric artery through collaterals coming
from superior mesenteric artery or internal iliac arteries or
lumbar arteries. The treatment consists of embolising
these arteries by endovascular techniques, by CT guided
glue injection or selective catheterization of inferior
mesenteric artery through superior mesenteric artery
collaterals and coil embolisations. Sometimes
laparoscopic clipping of inferior mesenteric artery may be
necessary.
Type III Endoleak: It is a leak due structural failure of
endograft because of tear in the fabric. This may require
placement of an additional stent graft within the graft.
Type IV Endoleak: It is because of the porosity of the
graft material. It is seen more commonly in Dacorn grafts
and is always self limiting.
Intestinal ischemia: This usually occurs if both the
internal iliac arteries are either coiled or excluded by ELG.
Symptoms appear from the third day and the patient
presents with lower abdominal pain and blood tinged
stools. In severe cases, reimplantation of the internal iliac
artery may be required.
Gut ischemia may also occur because of small cholesterol
emboli which may sometimes lead to bowel perforation.
Renal failure: Usually occurs because of cholesterol
emboli during manipulation of the stent graft across renal
arteries. It may also occur because of inadvertent covering
of renal arteries due to inaccurate placement of the stent
graft. If a large amount of radiographic contrast is used,
the patient may develop contrast induced nephropathy.
Post implantation fever: This occurs because of auto
immune reaction triggered by the stent fabric. The fever
starts 2-3 days after the stent procedure and may persist for
2 to 3 weeks. It responds to non-steroidial anti
inflammatory agents. Patients usually have fever
leucocytysis and raised CRP, interleukin – 6 and tumor
necrosis factor.
Infection: It is a rare but a serious complication and
should be treated with aggressive antibiotics. It can be
avoided by good sterility in the cath lab.
Migration of the endograft: this is a rare complication
with the newer devices. It is mostly related to neck
dilatation and angulation. It can be avoided by supra renal
fixation of stent graft by hooks or barbs. Different types of
endovascular grafts are available in the market. Few of
them (Aneuryx, Talent, Gore, COOK’S) are FDA
approved and are undergoing extensive clinical trials. The
stent grafts for excludingAAAare essentially of two types
(Table 2).
(i) Aorto-aortic tubular stent graft (Parodi’s endograft)
(ii) Aorto-uni iliac stent graft
(iii) Aorto bi iliac stent graft (modular stent grafts)
Result of various clinical trials in treatment of aortic
aneurysms and dissections
DREAM (Dutch Randomized Endovascular
Aneurysm Management) trial, was a multicentre,
randomized trial involving 24 centres in Netherland’s and
4 centres in Belgium comparing open repair with
endovascular repair in 345 patients having AAA of at least
5 cm in diameter, and who were considered suitable
candidates for both techniques.
Only endovascular devices approved by US, FDA or
that had Investigational Device Exemption (IDE) were
allowed in the study. The complications were classified
and graded according to SVS / ISCVS (Society of
Vascular Surgery / Interventional Society of Cardio
Vascular Surgery) practices.

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Compared to open repair, endovascular repair
resulted in significantly shorter duration, less blood
loss 1654 mL Vs 394 mL (P<0.001), lower rate of use of
post operative mechanical ventilation (P<0.001), shorter
stay in ICU (P<0.001) and shorter hospital stay
(P<0.001).
The operative mortality was 4.6% (8 of 174 patients) in
open repair group and 1.2% (2 of 171 patients) in
endovascular repair (Endovascular Aortic Repair) Group,
resulting in risk ratio of 3.9. The combined rate of
operative mortality and severe complications was 9.8% in
open repair group (17 of 174 patients) and 4.7% (8 of 171
patients) in endovascular repair group, resulting in risk
ratio of 2.1.
Three other randomized trials comparing open repair
with endovascular repair are Endovascular Aneurysm
Repair (EVAR-1) trial in UK, ACE trial in France and the
Open Versus Endovascular Repair (OVER) trial in US.
The ACE and OVER trial are ongoing. The EVAR-1 trial
results are similar to DREAM trial. Both had patients with
low surgical risk.EVAR-1 trial had an operative mortality
of 5.8% in the open repair group vs 1.9% in endovascular
repair group resulting in risk ratio of 3.1 similar to the
DREAM trial.
These data cannot be generalized because the patients
in EVAR-1 and DREAM were relatively of lower risk.
There are some trials like EVAR-2 and US IDE trials
analysis which compare treatments in patient who are at
high risk for open repair. Moreover, patients’ eligibility
for endovascular repair is dependent on state of device
technology existing at that time. Also age is a well known
predictor of mortality after repair of AAA, open and
endovascular repair may yield similar results in relatively
young patient at low surgical risk, where as endovascular
repair may particularly be advantageous in older and high
risk groups.
The Gore TAG Pivotal Trial was published in 2005. It
was undertaken to determine the safety and efficacy of
device treatment for descending thoracic aortic aneurysm
in comparison with open surgical repair. The early result
show that with TAG repair as compared to open repair, the
operative mortality was reduced by 65% (2.1% in TAG
group or 11.7% in open repair, P<0.001). Spinal Cord
Ischemia (SCI) developed only in 2.8% with endovascular
repair as compared to 13.8% in open surgical group
(P<0.001). The vascular complications occurred more
commonly in TAG Group (14% v/s 4%). The late outcome
shows that two years mortality was 24% in TAG group and
26% in surgical group. The major adverse effect at one
Table 2. Types of stent grafts for treatingAAA- Main body grafts
Company Main Body liac Leg(s) Main Body Delivery Fixation Stent Stent
Product System Profile Location Expansion Material
Length Dia Length Dia Device Sheath Delivery
(cm) (mm) (cm) (mm) Outer Required Sheath
Diameter for OD
(OD) Delivery?
Cook/Zenith 7.4, 8.8, 22-32 3.7 – 12.2 8, 10, 12, N/A No 20 F for Suprarenal Self- Stainless
10.3, 11.7, 14 – 24 23F Expanding Steel
13.2
Endologix/ 8, 10, 12+ 25, 28, 4, 505 16 21 F No N/A Infrarenal Self- Cobalt-
Powerrlink 34+ (25 and or Expanding chromium
28 mm), Su[rarenal alloy
22 F+ (25,
28, and
34 mm)
Gore/Exluder 14, 15, 16, 23, 26, 9.5, 10, 12, 14.5, 18 F Yes 20.5 F Infrarenal Self- Nitinol
17, 18 28.5, 31 11.5, 12, 16, 18, Expanding
13.5, 14 20
Medtronic/ 13.5, 16.5 20 - 28 8.5, 11.5 12, 13, 21 F No N/A Infrarenal Self- Nitinol
AneuRx 14, 15, Expanding
16
Medtronic/ 14, 15.5, 24 - 34 7.5, 9, 8, 10, 22 F No N/A Suprarenal Self Nitinol
Talent 17 cm 10.5 12 – 24 (24 – Expanding
(covered 28 mm),
length) 24 F
(30 –
34 mm)

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Apollo Medicine, Vol. 8, No. 3, September 2011 226
year was significantly lower after TAG repair (42%) then
after open repair (77%). The same trend was observed
throughout the three year follow-up. No device related
deaths were noted in the three years follow up and it was
concluded that endovascular repair with the Gore TAG
endovascular graft has shown safety and efficacy with
improved mid-term result compared to open surgical
repair. Long term effects are essential to ensure the best
outcome.
Recently EVAR-2 trial (2005) was published as a
follow up of 338 patient aged ≥60 years who had AAA
of at least 5.5 cm, in diameter and who meet high
surgical risk criteria for open repair due to cardiac,
pulmonary in renal co-morbidities. The patients were
randomized to Endovascular repair (EVAR) or no
treatment. The 30 days mortality for EVAR in
EVAR-2 trial was 9% and at 4 years was 14% for EVAR
and 19% for no intervention (P=NS). Overall 4 years
survival was only 34% in EVAR and 39% in no
intervention group (P=NS). EVAR-2 trial suggested that
endovascular repair is not a safe procedure in high risk
patients.
This result was challenged in Sixteenth Annual
Meeting of the Society for Vascular Surgery at
Philadelphia in June 2006 as the US IDE trials
Analysis which was a meta analysis of five trials for
Interventional Device Exemption (IDE) and was a Open
Surgical Versus Endovascular Repair long term outcome
measures in patient who are high risk for open surgery.
The primary outcome was AAA related deaths, all cause
death and aneurysm rupture, secondary outcomes were
endoleaks, AAA sac enlargement and stent-graft
migration.
Taken together DREAM trial and EVAR-1with
low risk subsets and US IDE trials analysis with high
risk groups indicates that endovascular repair can
be undertaken in a wide spectrum of patients with
AAA with equal or even better short (DREAM
trial EVAR-1 trial) and long term (US IDE analysis)
outcome.
The European Collaborators on Stent Graft
Techniques for Abdominal and Thoracic Aortic Aneurysm
Repair (EUROSTAR) registry, participant and progress
report published in Jan 2006 is the largest published series
which summarizes baseline, procedure and follow-up
results of patient who received stent graft for Abdominal
Aortic Aneurysm in 7988 patient followed up for a period
of eight years and 568 patient of Thoracic aneurysms and
dissection followed up for five years. The follow-up data
is summarized below.
Eurostar data registry centre for endograft
treatment ofAAA
Eight years follow-up outcome (n=7968)
Freedom from death 60%
Freedom from Endoleaks 70.5%
Freedom from persistent Endoleaks 89.5%
Freedom from death and persistent Endoleaks 52.1%
Freedom from secondary intervention 81.4%
Freedom from secondary intervention and death 47.7%
Freedom from Rupture 97.8%
The survival after 8 years was 60% which is
significantly better than that reported in EVAR-2 and US
IDE trials where the survival was 56% at 4 years. But
EVAR-2 and US IDE trial patients were much sicker the
patients in EUROSTAR registry.
Eurostar data registry for thoracic aorta
aneurysm and dissection
5 year follow-up outcome (n=625)
Freedom from death 60%
Freedom from Endoleaks 84%
Freedom from persistent Endoleaks 99%
Freedom from Death and Persistent Endoleaks 63%
Freedom from Secondary Intervention 82%
Freedom from Death & Secondary Intervention 56%
Freedom from Rupture 98.2%
These results show the non-inferiority of
Endovascular treatment in comparison to open repair and
the advantages of relatively less invasive form of
treatment with less blood loss, less hospitalization stay
and less monitoring in ICU.
Personal experience of Tevar and Evar
Total Tevar Evar
Number of Cases 189 99 90
DissectingAneurysm 36 34 2
Hybrid 9 8 1
Chimney 3 2 1
Operative Mortality 1 1 0
Follow up at 1 year
Number of Cases 152 80 72
Endoleak 9 1 8
Persistant Endoleak 2 0 2
Secondary Interventions 8 3 5

12. Review Article
227 Apollo Medicine, Vol. 8, No. 3, September 2011
Death 2 1 1
Rupture 1 1 0
Follow up at 5 years
Number of Cases 45 25 30
Endoleak 2 1 1
Death 3 2 1
CONCLUSION
Aortic Aneurysms can now be treated successfully by
endovascular techniques. Various studies like DREAM.,
US IDE trial, EUROSTAR registry, EVAR-1 and GORE
pivotal TAG trial have suggested, safety, efficacy and
durability of endovascular stent grafting for treating
aneurysms and dissections of aorta. The advantages of
endovascular repair are reduced incidence of bleeding
reduced ICU stay, early ambulation and safety of the
procedure.
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