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J Thorac Cardiovasc Surg 2008;136:278-279
© 2008 The American Association for Thoracic Surgery

Editorial

Why are we still talking about open repair of descending aneurysms?

Columbia University Medical Center, New York, New York

Received for publication May 27, 2008; accepted for publication May 31, 2008.

^_* Address for reprints: Allen Stewart, MD, Columbia University Medical Center, 177 Fort Washington Ave, MHB 7GN-435, New York, NY 10032. (Email: as2276@columbia.edu).

The first 20% of the full text of this article appears below.

Since Alexander and Byron¹ performed the first surgical intervention on a descending thoracic aneurysm in 1943, several advances have been made in the field. The conduit choice has moved from homografts^2,3 to woven Dacron grafts. Methods to ameliorate heart strain and end-organ malperfusion syndrome progressed from surface hypothermia to arterial bypass shunts to partial left-sided heart bypass. Efforts to eliminate spinal ischemia have moved from "clamp and sew" to include lumbar drainage, administration of steroids, measurement of somatosensory evoked potentials, and evaluation of motor evoked potentials. These advancements, combined with an improvement in postoperative care, have resulted in a dramatic reduction in morbidity and mortality. In centers of excellence, a lower extremity paralysis rate less than 3.5%, a stroke rate less than 3%, and a mortality rate approximating 5% can be expected.⁴ Although open repair of descending thoracic aneurysms can be accomplished with a reproducibly low complication rate, it is an invasive procedure that requires a lengthy period of recovery.

Enthusiasm for a less-invasive solution began to gain traction with the successful endovascular repair of a thoracic aneurysm by Dake and colleagues.⁵ In 2005, the findings of the multicenter GORE TAG (WL Gore and Associates, Flagstaff, Ariz) study led to the US Food and Drug Administration approval for thoracic endovascular aortic repair (TEVAR).⁶ Initially, endovascular repair was limited to the elderly, patients with compromised functional status, and those with previous thoracic aortic interventions. Various medical subspecialties have since laid claim to the technology, including vascular surgeons, . . . [Full Text of this Article]