SOCIETY FOR VASCULAR SURGERY CLINICAL PRACTICE GUIDELINES FOR THORACIC ENDOVASCULAR ANEURYSM REPAIR (TEVAR).J Vasc Surg. 2020 Jul 03 [Online ahead of print]JV
Thoracic aortic diseases, including disease of the descending thoracic aorta (DTA), are significant causes of death in the United States. Open repair of DTA is a physiologically impactful operation with relatively high rates of mortality, paraplegia, and renal failure. Thoracic endovascular aneurysm repair (TEVAR) has revolutionized the treatment of DTA, and has largely supplanted open repair due to lower morbidity and mortality. These Society for Vascular Surgery (SVS) Practice Guidelines are applicable to the use of TEVAR for descending thoracic aortic aneurysm (TAA) as well as other rarer pathologies of the DTA. Management of aortic dissections and traumatic injuries will be discussed in separate SVS documents. In general, there is a lack of high-quality evidence across all TAA pathologies, highlighting the need for better comparative effectiveness research. Yet, large single center experiences, administrative databases and meta-analyses have all consistently reported beneficial effects of TEVAR over open repair, especially in the setting of rupture. Many of the strongest recommendations from the present guideline focus on imaging either prior to, during or after TEVAR and include: 1) in patients considered at high risk for symptomatic TAA or acute aortic syndrome, we recommend urgent imaging, usually Computed Tomography Angiography (CTA) due to its speed and ease of use for pre-operative planning. Level of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate), 2) if TEVAR is being considered, we recommend fine cut (less than or equal to 0.25 mm) CTA of the entire aorta, as well as the iliac and femoral arteries. CTA of the head/neck is also needed to determine the anatomy of the vertebral arteries. Level of recommendation: Grade 1 (Strong), Quality of Evidence: A (High), 3) we recommend routine use of three-dimensional centerline reconstruction software for accurate case planning and execution in TEVAR. Level of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate), and 4) we recommend contrast-enhanced CT scanning at one and 12 months after TEVAR, and then yearly for life, with consideration of more frequent imaging if an endoleak or other abnormality of concern is detected at one month. Level of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate). Finally, based on our review, in patients who could undergo either technique (within the criteria of the device's IFU), we recommend TEVAR as the preferred approach to treat elective DTA aneurysms given its reduced morbidity and length of stay, as well as short term mortality. Level of recommendation: Grade 1 (Strong), Quality of Evidence: A (High). Given the benefits of TEVAR, treatment using a minimally invasive approach is largely based on anatomic eligibility, rather than patient-specific factors as is the case in open TAA repair. Thus for isolated DTA, TEVAR should be the primary method of repair in both the elective and emergent setting based on improved short- and mid-term mortality, as well as decreased morbidity.