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Page 2 of 5 Tanaka et al. Vessel Plus 2023;7:28 https://dx.doi.org/10.20517/2574-1209.2023.108

[1]
repair . Since that time, intraoperative and perioperative management have evolved to improve operative
outcomes. The adjunct of distal aortic perfusion, hypothermia, and cerebrospinal fluid drainage have
significantly reduced the incidence of spinal cord injury. In addition, visceral blood perfusion and cold
[2,3]
crystalloid perfusion of the renal arteries are used to protect the viscera and kidneys . However, the early
mortality and morbidity rate of this procedure remains significant . In the early 1990s, endovascular aortic
[2,3]
aneurysm repair (EVAR) emerged as a less-invasive alternative to treat infrarenal abdominal aortic
aneurysms . By the late 2000s, EVAR became the first-line treatment option for both infrarenal abdominal
[4]
and descending thoracic aortic aneurysms (DTAA). However, EVAR has not yet become the gold standard
for treating TAAAs.

The anatomical complexities of TAAAs, which make open TAAA repair difficult, such as the involvement
of visceral/renal branches and spinal cord blood supplies, are also challenges to EVAR. Hybrid TAAA repair
was proposed to solve the anatomical constraints of EVAR with fewer surgical insults than open repairs by
[5]
sparing thoracotomy. However, outcomes after hybrid TAAA repair were not superior to open repair .
Another alternative approach is total endovascular repair, with visceral parallel graft (chimney/snorkel)
techniques using off-the-shelf devices. Nevertheless, the use of parallel graft has raised concerns for
durability due to the “gutter” leaks . The physician-modified, multi-branched/fenestrated stent graft was
[5]
introduced in the late 1990s and, currently, off-the-shelf and custom-made branched/fenestrated stent grafts
to treat TAAA are under investigational use in the United States .
[6]
[7]
In the recently published 2022 ACC/AHA Guidelines for the aortic disease , all the recommendations are
derived from nonrandomized and limited data. The use of open repair was Class I recommendation in
patients with ruptured TAAA and with intact TAAA in Marfan syndrome, Loeys-Dietz syndrome, and
vascular Ehlers-Danlos syndrome. On the other hand, endovascular repair was a Class 2b recommendation
but is limited to centers with endovascular expertise and access to appropriate endovascular stent grafts, in
patients with both hemodynamically stable ruptured TAAA and intact degenerative TAAA with suitable
anatomy.

This manuscript discusses patient selection for open and endovascular repair of TAAA from a literature
review and our institutional experience.

METHODS
Because of the technical complexity of both open and endovascular TAAA repairs and low case numbers
across the United States, a paucity of data exists on which patient population would benefit most from open
and endovascular approaches. A systematic search of the literature was performed using PubMed and
Cochrane database with the keywords “thoracoabdominal aortic aneurysm", “open repair or open surgery”,
“endovascular or stent graft” and “comparative study or trial”.

COMPARATIVE STUDIES
There are no direct comparative studies on outcomes after open vs. endovascular TAAA repairs. The closest
[8,9]
study is our institutional experience in DTAA repairs . We found that DTAA patients with sarcopenia are
at risk for postoperative adverse events in both open and endovascular approaches, especially sarcopenic
[8]
patients, who underwent open surgical repair carry significantly increased long-term mortality risk . We
have also published that TEVAR reduced mortality fourfold compared to open repair when patients with
DTAA had chronic obstructive pulmonary disease, glomerular filtration rate < 60 mL/min,
and age > 70 years .
[9]