Thoracic Endovascular Aneurysm Repair (TEVAR)
Publication Date: July 3, 2020
Last Updated: May 23, 2022
Recommendations
Diagnosis
In patients considered at low or intermediate risk for a thoracic aortic aneurysm (TAA) based on their history and physical examination findings, we suggest chest X-ray as the first radiographic test, as it may identify an alternative diagnosis for symptoms and may obviate the need for additional aortic imaging. ( 2 – Weak , C)
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In patients considered at high risk for symptomatic TAA or acute aortic syndrome, we recommend urgent imaging, usually computed tomography angiography (CTA) because of its speed and ease of use for preoperative planning. Magnetic resonance angiography (MRA) and transesophageal echocardiography (TEE) are also adequate for screening to identify thoracic aortic disease, but have limited applicability in certain scenarios (discussed further below). ( 1 – Strong , B)
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For elective TEVAR cases, we suggest assessment of left ventricular function by transthoracic echocardiography in a patient with dyspnea of unknown origin or in a patient with known congestive heart failure with worsening dyspnea. ( 2 – Weak , C)
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If TEVAR is being considered, we recommend fine-cut (≤0.25 mm) CTA of the entire aorta, as well as the iliac and femoral arteries. CTA of the head and neck is also needed to determine the anatomy of the vertebral arteries. ( 1 – Strong , A)
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We recommend routine use of three-dimensional centerline reconstruction software for accurate case planning and execution in TEVAR. ( 1 – Strong , B)
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We suggest contrast-enhanced MRA for preoperative planning for patients with severe allergy to iodinated contrast material. ( 2 – Weak , C)
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We recommend intravascular ultrasound (IVUS) use in TEVAR for TAA to assess landing zones when cross-sectional imaging is of poor quality, a more detailed evaluation of landing zones or branch vessel origins is needed, or a decrease in contrast material use is desired. ( 1 – Strong , B)
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Treatment
As hypertension is a modifiable risk factor for the development of aortic aneurysms and is associated with accelerated aortic growth and rupture, we recommend that blood pressure be managed to the adherence of the ACC/AHA guidelines. ( 1 – Strong , B)
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We recommend interventions for smoking cessation in patients with thoracic aortic disease, as even passive exposure may increase the risk of aortic rupture. ( 1 – Strong , A)
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In patients who could undergo either technique (within the criteria of the device’s instructions for use, 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. ( 1 – Strong , A)
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We recommend TEVAR in asymptomatic patients with a descending TAA when the maximum aneurysm diameter exceeds 5.5 cm in “low-risk” patients with favorable aortic anatomy. ( 1 – Strong , B)
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We suggest using higher aortic diameter thresholds for TEVAR in patients deemed to have a particularly high risk of death, renal failure, or paraplegia from the procedure, where the benefit of treatment is lower than the risk posed by the natural history of the TAA. ( 2 – Weak , C)
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Because of the dynamic nature of isolated intramural hematoma (IMH) and its known association with aortic dissection (AD), we recommend close observation and hypertension control with follow-up imaging as the initial management of patients with asymptomatic IMH. ( 1 – Strong , B)
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We recommend TEVAR in patients with IMH or penetrating aortic ulcer (PAU) who have persistent symptoms, complications or show evidence of disease progression on follow-up imaging after a period of hypertension control. ( 1 – Strong , B)
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We suggest TEVAR in selected cases of asymptomatic PAU who have at-risk characteristics for growth or rupture. ( 2 – Weak , B)
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We suggest TEVAR for symptomatic mycotic/infected TAA as a temporizing measure, but data demonstrating long-term benefit are lacking. ( 2 – Weak , C)
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We recommend increasing perfusion pressure through controlled hypertension (mean arterial pressure >90 mm Hg) as a component of a spinal cord protection protocol in patients at high risk of spinal cord injury because of extensive coverage length (>15cm), poor hypogastric perfusion (occluded or significantly stenosed hypogastric arteries), or coverage of important collaterals (subclavian/hypogastric arteries). ( 1 – Strong , B)
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We recommend prophylactic cerebrospinal fluid (CSF) drainage for spinal cord injury protection in TEVAR cases that are deemed high risk (covering extensive length of descending aorta, previous aortic coverage, including EVAR or open abdominal aortic aneurysm (AAA) repair, compromised pelvic perfusion with diseased or occluded common or internal iliac arteries, diseased or occluded vertebral arteries, planned left subclavian artery coverage (LSA), or deemed high risk by the operating surgeon). ( 1 – Strong , B)
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For elective TEVAR of a TAA where coverage of the LSA is necessary for adequate stent graft seal, we suggest preoperative or concomitant LSA revascularization. ( 1 – Strong , B)
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For patients in whom the anatomy to be treated compromises perfusion to vital structures (see below), we recommend LSA revascularization. ( 1 – Strong , B)
- Examples of these circumstances include:
- Presence of a patent left internal mammary artery (LIMA) to coronary artery bypass graft
- Termination of the left vertebral artery into the posterior inferior cerebellar artery
- Absent, atretic, or occluded right vertebral artery
- Patent left arm arteriovenous shunt for dialysis
- Prior infrarenal aortic operation or EVAR with previously ligated or covered lumbar and middle sacral arteries
- Planned extensive coverage (≥15 cm) of the DTA
- Hypogastric artery occlusion or significant occlusive disease
- Presence of aneurysm disease in the young patient, for whom future therapy involving the distal thoracic aorta may be necessary
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For patients with acute thoracic emergencies, where TEVAR is required urgently and coverage of the LSA is necessary, it is suggested that revascularization should be individualized and addressed on the basis of the patient’s anatomy and urgency of the procedure. ( 2 – Weak , B)
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We recommend preprocedural TEVAR planning to include sizing and landing sites before the case to minimize procedural contrast material use. If available, intraoperative CTA overlay technology and IVUS should be used to minimize use of contrast material. ( 1 – Strong , B)
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We recommend nonionic, hypo-osmolar contrast material with attempts at minimizing intra-arterial contrast agent use, especially in patients at high risk for contrast-induced nephropathy (CIN). ( 1 – Strong , B)
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Depending on the patient’s corporal density and the capacity of the X-ray equipment available, we suggest diluting contrast material in the power injector when possible (typically to 50% or 70%). Adjustments in injection volume and time (faster injection of smaller doses) can usually compensate when additional visibility is required. ( 2 – Weak , C)
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We suggest the use of on-table mapping software options on fixed-imaging X-ray systems, such as roadmapping, CT fusion or overlay reference, to aid in locating target landing sites and to minimize need for repeated injections. If available, CT overlay capability is extremely useful, especially in cases in which location and cannulation of branches will be needed. ( 2 – Weak , B)
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To decrease the risk of atheroembolization, we recommend minimizing intraortic wire, catheter, and endograft manipulation in the aortic arch and at or above the visceral/renal arteries, especially in patients with significant aortic atheromatous disease or thrombus. ( 1 – Strong , B)
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We recommend minimizing the dwelling time of large or occlusive iliofemoral artery sheaths to decrease the risk of spinal cord ischemia and lower extremity ischemia that can lead to postoperative compartment syndrome or rhabdomyolysis. In cases in which a large sheath must be left in place for a prolonged time, it can be withdrawn into the external iliac artery to allow antegrade flow into the ipsilateral internal iliac artery. Meticulous postoperative vigilance to detect inadequate lower extremity perfusion or compartment syndrome should be routine. ( 1 – Strong , B)
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We recommend pre-emptive superior mesenteric artery (SMA) stenting with a balloon-expandable stent in cases of >50% stenosis of the SMA in the following conditions: before or after celiac artery (CA) coverage or encroachment, with TEVAR that is encroaching on the SMA origin, or in any patient otherwise considered at high risk for post-TEVAR mesenteric ischemia. ( 1 – Strong , B)
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In anticipation of high risk for CA territory ischemia (nonvisualization of CA collateral branches by CTA or dedicated SMA angiography), we recommend open or endovascular revascularization of the CA before TEVAR. ( 1 – Strong , B)
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If an open approach for access is used, we recommend transverse or oblique incisions in performing open femoral access for TEVAR. ( 1 – Strong , B)
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We recommend using ultrasound guidance for percutaneous access to improve procedural success and to decrease the rate of major complications. ( 1 – Strong , B)
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We recommend that percutaneous access for TEVAR is safe and an acceptable alternative to open common femoral artery exposure if certain anatomic criteria are met—e.g., diameter of common femoral artery, lack of front wall calcium, etc. ( 1 – Strong , B)
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We recommend the use of iliac conduits or direct iliac/aortic punctures for TEVAR delivery to facilitate access in patients with small (relative to the chosen device), tortuous, or calcified iliac vessels. The decision to perform a conduit should be made in the preoperative setting, when possible. ( 1 – Strong , B)
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We suggest that endoconduits to facilitate access for TEVAR are an acceptable alternative to an open iliac conduit in some cases, but few data comparing them with an iliac conduit or long-term data describing their outcomes over time are available. ( 2 – Weak , C)
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We recommend TEVAR over open repair for the treatment of ruptured DTA when anatomically feasible. ( 1 – Strong , B)
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We recommend contrast-enhanced CT scanning at one month and twelve 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. ( 1 – Strong , B)
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Recommendation Grading
Overview
Title
Thoracic Endovascular Aneurysm Repair (TEVAR)
Authoring Organization
Society for Vascular Surgery
Publication Month/Year
July 3, 2020
Last Updated Month/Year
October 17, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
Thoracic aortic diseases, including disease of the descending thoracic aorta (DTA), are significant causes of death in the United States. Open repair of the DTA is a physiologically impactful operation with relatively high rates of mortality, paraplegia, and renal failure. Thoracic endovascular aortic repair (TEVAR) has revolutionized treatment of the DTA and has largely supplanted open repair because of lower morbidity and mortality. These Society for Vascular Surgery Practice Guidelines are applicable to the use of TEVAR for descending thoracic aortic aneurysm (TAA) as well as for other rarer pathologic processes of the DTA.
Target Patient Population
Patients with descending thoracic aortic aneurysms
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Emergency care, Hospital, Operating and recovery room
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Assessment and screening, Treatment, Management
Diseases/Conditions (MeSH)
D001014 - Aortic Aneurysm, D017545 - Aortic Aneurysm, Thoracic, D000783 - Aneurysm
Keywords
aneurysm, aortic aneurysm, TEVAR, thoracic aortic aneurysm, TAA, descending thoracic aorta, DTA
Source Citation
Upchurch GR Jr, Escobar GA, Azizzadeh A, et al. Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms. J Vasc Surg. 2021;73(1S):55S-83S. doi:10.1016/j.jvs.2020.05.076