Endograft Repair in the Thoracic Aorta: Poised to Grow!

The article by Halawa et al on thoracic stent-grafts¹ serves as an appropriate platform for this issue’s Editor’s Corner. Arguably, 2008 was the “coming-out” year for these technologies, as two additional endograft devices received FDA approval. We now have a total of three commercially available and “off-the-shelf” thoracic devices. While treatment of aneurysms in the descending aorta represents the approved on-label indication, physicians — no doubt — will also use them off-label in the management of patients with a host of other similarly serious pathologies.

The three major stent-graft manufacturers (W.L. Gore, Flagstaff, Arizona, Cook Medical, Bloomington, Indiana, and Medtronic Cardiovascular, Santa Rosa, California) are now actively pursuing thoracic endovascular aortic repair (TEVAR). A growing number of surgeons (and a few others) will be performing thoracic endograft interventions as the landscape changes dramatically, with many more hospitals and physicians anticipated to enter a field that was essentially “reserved for the chosen few” since the inception of these therapies a little more than 10 years ago. Significant gains in procedure rates and volumes will be the likely result in the near future. Whether such developments will turn out to be in the best interest of all — patients in particular — remains to be seen, but no one disputes the obvious reality that TEVAR represents a most important advancement, as it provides the necessary tools for less-invasive repair of life-threatening thoracic aortic lesions that, until recently, could only be treated using risky and technically complex operative approaches. And while the open-surgery strategy can produce very good results, only few centers of excellence (worldwide) seem capable of achieving that, leaving many — if not most — patients without a reasonable treatment option.

At the same time, it is also appropriate to note that endovascular thoracic technologies are far from optimal, with significant unresolved issues still awaiting the emergence of better solutions. Additionally, we have only insufficient information on the performance of the various stent-grafts, and find ourselves often unable to make truly evidence-based decisions.² That notwithstanding, the therapy is clearly evolving rapidly, and it would not be unreasonable to predict that TEVAR is destined to eclipse, if not replace open surgical repair in the treatment of several common indications for thoracic aortic intervention in the near future. In closing, this is where we are today: TEVAR technologies and techniques have made enormous progress during their relatively short 15-year existence.³ They are emerging as nothing short of an icon for the power of Endovascular procedures, revolutionizing the entire field of thoracic aortic surgery in the process. But it is too soon to declare “total triumph” due to the incomplete and early nature of some of these developments and unmet needs in important areas such as the ascending aorta, total arch repair, and branched endografts. Stay tuned…