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J Thorac Cardiovasc Surg 2007;133:369-377
© 2007 The American Association for Thoracic Surgery
Surgery for Acquired Cardiovascular Disease |
a Division of Cardiothoracic Surgery, Hospital of the Unversity of Pennsylvania Philadelphia, Pa
b Division of Cardiac Surgery, Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada
c Division of Vascular Surgery, University of Pittsburgh, Pittsburgh Pa
d Statistics Collaborative, Inc, Washington, DC
e Division of Cardiothoracic Surgery, Stanford University, Stanford, Calif
Received for publication April 24, 2005; revisions received May 4, 2006; accepted for publication July 12, 2006. * Address for reprints: Joseph E. Bavaria, MD, Brooke Roberts Professor of Surgery, Division of Cardiothoracic Surgery, 4 Silverstein, Hospital of University of Pennsylvania, 3400 Spruce St, Philadelphia, Pa 19104 (Email: joseph.bavaria{at}uphs.upenn.edu).
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Abstract |
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METHODS: Between September 1999 and May 2001, 140 patients with descending thoracic aneurysms were enrolled at 17 sites and evaluated for a Gore TAG Thoracic Endograft. An open surgical control cohort of 94 patients was identified by enrolling historical and concurrent subjects. Patients were assessed before treatment, at treatment, and at hospital discharge and returned for follow-up visits at 1 month, 6 months, and annually thereafter.
RESULTS: One hundred thirty-seven of 140 patients had successful implantation of the endograft. Perioperative mortality in the endograft versus open surgical control cohort was 2.1% (n = 3) versus 11.7% (n = 11, P < .001). Thirty-day analysis revealed a statistically significant lower incidence of the following complications in the endovascular cohort versus the surgical cohort: spinal cord ischemia (3% vs 14%), respiratory failure (4% vs 20%), and renal insufficiency (1% vs 13%). The endovascular group had a higher incidence of peripheral vascular complications (14% vs 4%). The mean lengths of intensive care unit stay (2.6 ± 14.6 vs 5.2 ± 7.2 days) and hospital stay (7.4 ± 17.7 vs 14.4 ± 12.8 days) were significantly shorter in the endovascular cohort. At 1 and 2 years’ follow-up, the incidence of endoleaks was 6% and 9%, respectively. Through 2 years of follow-up, there were 3 reinterventions in the endograft cohort and none in the open surgical control cohort. Kaplan–Meier analysis revealed no difference in overall mortality at 2 years.
CONCLUSIONS: In this multicenter study early outcomes with descending aortic endovascular stent grafting were very encouraging when compared with those of a well-matched surgical cohort. However, at 2 years’ follow-up, there is an incidence of endoleaks and reinterventions associated with endovascular versus open surgical repair. Continued vigilant surveillance of patients treated with an endograft is important.
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Introduction |
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Although more than 10 years have passed since the first endovascular treatment of a descending thoracic aortic aneurysm (DTA), there has been only one comparative report of open versus endovascular repair.1
The prevalence of thoracic aortic aneurysms has appeared to triple in the 2 most recent decades.2,3 Whether this represents an increase in the elderly proportion of our population, improved diagnostic capabilities, or an actual increase in incidence is unknown. Thoracic aortic aneurysms are now estimated to affect 10 of every 100,000 elderly adults, with 30% to 40% of these being DTAs. Although open repair has become a refined surgical procedure, with extracorporeal circulation for peripheral organ preservation and multiple techniques for spinal cord protection, it has nevertheless been associated with significant mortality, and the cumulative morbidity in this aged population frequently exceeds 50% to 70%.4,5 The highly invasive nature of this procedure necessitates a prolonged recovery period, with return to well-being frequently delayed 4 to 6 months postoperatively. Additionally, high-risk patients previously denied surgical repair might become surgical candidates if a less-invasive endovascular option were possible. For the above reasons, an endovascular repair is highly attractive.
This report documents the results of the phase II W. L. Gore Tag Multi-Center Trial comparing the results of endovascular repair with those of an open surgical control group. The results of this study comprise the data presented for US Food and Drug Administration panel review.
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Materials and Methods |
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All adverse events were reported by individual sites. These events were then verified by independent study monitors. Finally, a clinical events committee consisting of 4 endovascular and cardiothoracic physicians reviewed selected adverse events to ensure consistent adverse event classification. This report includes data collected through the 24-month follow-up visit. Follow-up through 5 years continues.
Surgical Treatment
Open surgical repair was accomplished by means of the routine in place at each member institution. The use of spinal drainage was variable. The majority (82%) of the open surgical control group was composed of subjects with procedure dates ranging from January 1998 through May 2001. The remaining had a procedure date earlier than 1998.
Patients in the endograft group were treated with the Gore TAG endoprosthesis, a flexible polytetrafluoroethylene graft with a nitinol exoskeleton. The device is inserted through a 20F, 22F, or 24F (OD) sheath, depending on device size. Iliac and femoral vessel size and degree of calcification were assessed preoperatively on CT scan to allow for smooth introduction of the device. Procedures were performed in surgical or radiology suites with fluoroscopic control, usually after achievement of general anesthesia.
In June 2001, the sponsor received reports of fractures in the longitudinal support spine. Based on this, the device was voluntarily withdrawn from the market in November 2001. Of the 19 reported fractures, only 1 required further intervention. The device was modified and subsequently tested in a confirmatory study between January and June 2004.
Statistical Methods
Selected baseline characteristics are compared between the endograft and surgical control cohorts. Continuous variables are summarized by using means, standard deviations, and percentiles (eg, medians). Comparison of continuous variables between groups uses 2-sample t tests. Where normality does not hold, a Wilcoxon rank sum test was used. Categoric variables are summarized by using counts and percentages. Between-group comparisons for these variables use the Fisher exact test. Survival analyses use the Kaplan–Meier method. All tests use a 5% 2-tailed type I error rate. No statistical adjustment for multiple testing has been made, and P values are considered exploratory. Because of the limits of data collection in the open surgical control group, a large percentage of the aortic morphology characteristics are missing. For these variables, the distributions are presented, but no tests of significance are indicated.
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Results |
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Subject demographics, previous medical history, and pretreatment aortic morphology are listed in (Tables E1 and E2). There was no significant difference in age, sex, body mass index, aneurysm size or aneurysm length, previous coronary artery disease, congestive heart failure, stroke, peripheral arterial disease, or American Society of Anesthesiologists class in the endograft group versus the open surgical control cohort. There was a higher incidence of symptomatic aneurysms (38% vs 21%, P = .007) in the surgical control group. The aortic diameter immediately proximal (30.8 ± 4.1 vs 33.9 ± 8.3 mm) and distal (29.8 ± 3.7 vs 33.6 ± 7.1 mm) to the aneurysm was larger in the surgical control group.
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Patients in the open surgical control cohort underwent left thoracotomy and aneurysm resection with interposition graft placement. Seventy-eight percent of aneurysms were repaired with extracorporeal circulatory support. Spinal drainage was variable as per the protocol at each member institution.
Perioperative mortality
Operative mortality defined as death within 30 days of the procedure or on the same hospital admission was 2.1% (n = 3) in the endograft group versus 11.7% (n = 11) in the open surgical control cohort (P = .004).
ENDOGRAFT COHORT. One early death was due to a postoperative stroke, and another was due to a cardiac event on postoperative day 15. The third death occurred nearly 7 months after the procedure from septic complications after a long, complicated in-hospital course after respiratory arrest. At autopsy, this patient had an aortoesophageal fistula.
OPEN SURGICAL CONTROL COHORT. The causes of death among the 11 perioperative mortalities in the open surgical cohort were respiratory failure (n = 6), cerebrovascular accident (CVA; n = 3), cardiac arrest (n = 1), and aortoesophageal fistula (n = 1).
Spinal cord ischemia
The total spinal cord ischemia incidence was 2.9% (4/140) in the endograft cohort versus 13.8% (13/94) in the open surgical control group (P = .003). In the endograft cohort 3 patients had paraplegia, and 1 had paraparesis. Of the 4 patients, 2 were fully recovered, and 2 had residual weakness. Three of the 4 cases of spinal ischemia were diagnosed soon after surgical intervention, and 1 was clearly related to ileofemoral bleeding and postprocedural hypotension. Two of 4 patients with spinal cord ischemia had previous abdominal aortic aneurysm (AAAs) treated with aortobifemoral bypass. Forty-two (30%) patients in the endograft group had previous infrarenal aortic replacement, resulting in a 4.8% rate of spinal cord events in the AAA and endograft subgroup. Paraplegia in patients without previous abdominal aortic replacement was 2% (P = .36, not significant). Three of 4 patients with spinal ischemia had multiple devices placed for a full left subclavian to celiac DTA pavement.
In the open surgical control cohort, of the 13 cases of spinal ischemia, 8 were paraplegia, and 5 were paraparesis. Six of the 8 cases of paraplegia resulted in death.
Cvas
CVA was defined as a new neurologic deficit (lasting >24 hours), as determined by CT/magnetic resonance imaging, clinical examination, or both. The incidence of CVA was similar in the endograft and open surgical control cohorts (3.6% [n = 5] vs 4.3% [n = 4], P = .58). Four of the 5 patients with a stroke in the endograft group had coverage of the left subclavian artery with the endograft for a proximal aneurysm and a carotid-subclavian bypass. Of 28 patients undergoing subclavian coverage, 4 (14%) had a CVA compared with 1% of patients in whom the graft terminated distal to the subclavian artery (P < .001).
Other perioperative complications
For other perioperative complications, see Table 2. The endovascular cohort had a lower incidence of respiratory failure and renal failure and a higher incidence of peripheral vascular complications. The mean length of intensive care unit stay (2.6 ± 14.6 vs 5.2 ± 7.2 days, P < .001) and total length of hospital stay (7.4 ± 17.7 vs 14.4 ± 12.8 days, P < .001) were significantly shorter in the endovascular cohort.
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Overall survival
Kaplan–Meier analysis reveals an estimated 2-year survival of 78% and 76% (P = .48) in the endograft group and the open surgical control cohort, respectively (Figure 1).
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Aneurysm regression
There were no cases of aneurysm rupture in either cohort. At 2 years’ follow-up, 45% (30/67) of the endovascular patients had a decrease in aneurysm size of 5 mm or greater, 42% (28/67) had no change (<5 mm), and 13% (9/67) had an increase in aneurysm size of 5 mm or greater.
Stent migration and fracture
There was 1 case of stent migration diagnosed by 2 years’ follow-up, with no clinical sequelae. Stent fractures were identified in 19 (14%) patients through 2 years after treatment. Only one fracture was associated with a clinical sequela, an endoleak that was successfully treated with an additional endograft.
Aortic reoperation
There were 3 reinterventions in the endograft group through 2 years after treatment. Two of the 3 reinterventions involved a repeat endovascular procedure with no operative mortality. One patient in the endovascular group was operated on with an open surgical technique 73 days after the initial procedure, when he presented with recurrent infections and positive blood cultures, and a presumptive diagnosis of an infected stent graft was made. Intraoperatively, the patient was found to have an aortoesophageal fistula that was treated with graft removal and extra-anatomic bypass. Postoperatively, this patient had multisystem organ failure and died.
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Discussion |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionConclusionsAppendixReferences |
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Although surgical resection is durable, perioperative mortality and morbidity are variable. Earlier reports suggest a perioperative mortality of 12% to 44%, depending on comorbid conditions8,9 and urgency of operation. More recent literature from expert high-volume centers report mortality in the range of 4% to 9% and incidence of paraplegia of less than 3% for isolated DTAs.10,11
As "minimally invasive" endovascular treatment has become technically feasible, initially with homemade first-generation grafts and now with commercially available thoracic endografts, it is being offered as an attractive treatment option to patients. Thoracic aortic endografts have been used with early success in small- to moderate-sized, retrospective, single-center series.12-17
We previously reported on the initial results of the Gore TAG Endograft.18 The present report includes a more in-depth and complete analysis of the initial data and, importantly, a comparative analysis with an open surgical control cohort. To our knowledge, this is the largest comparison of endovascular versus open surgical repair of DTA.
Although the open surgical control cohort in this study was not randomized, it is robust for several reasons:
Specific Findings of This Study
Perioperative results were generally improved in the endograft cohort versus the open surgical control cohort. Perioperative mortality was lower (2.1% vs 11.7%, P = .004). Lengths of intensive care unit and hospital stay were shorter. Postoperative respiratory and renal failure was lower in the endograft cohort.
The incidence of spinal cord ischemia was 2.9% (n = 4) in the endograft cohort versus 13.8% (n = 13, P = .003) in the open surgical control cohort. Theoretical reasons for lower spinal cord ischemia rates with an endovascular technique include no period of aortic crossclamping; fewer periods of perioperative hypotension associated with blood loss or hemodynamic shifts; the ability to tolerate higher mean arterial pressures because there are no suture lines; earlier awakening from general anesthesia, which allows one to tailor blood pressure management to neurologic examination; and slow thrombosis of the aneurysmal sac versus acute occlusion of critical vessels in surgical patients. The 2.9% incidence of spinal ischemia in the endovascular cohort (and 4.8% rate in patients with a previous AAA) is consistent with DTA endograft rates published in the literature of 3.6% to 6.5%.13-22
Importantly, 2 of the 4 patients with spinal ischemia in this study made a full recovery. Spinal drainage was not consistently implemented in this series. Guidelines19 for the use of cerebrospinal fluid drainage and somatosensory evoked potentials monitoring during DTA endograft procedures have been recently presented, and the recommendations for the use of these adjuncts are as follows: (1) patients with previous AAA repair and (2) full (subclavian artery to celiac axis) coverage of the descending aorta (DTA Extent C23).
The 13.8% incidence of spinal ischemia in the open surgical control cohort is higher than the recent best single-center published results of approximately 3%.9,10 This study’s higher rate might be due to several factors:
For the above listed reasons, we believe this higher incidence of 13.8% probably better reflects the expected incidence throughout the country for all comers.
The incidence of CVA during the first 30 days was similar in both cohorts (3.6% for the endograft group vs 4.3% for the open repair group). However, strokes in the endovascular group clustered around those patients who underwent coverage of the left subclavian artery. This result might reflect a greater proximal atherosclerotic burden at the aortic arch and brachiocephalic vessels in patients who require coverage of the subclavian artery. Patients who require endografting at the level of the arch might need different adjunctive operative strategies in the future to decrease the incidence of CVA in this group.
Follow-up
Open surgical repair is known to be a durable and long-lasting operation with a very low incidence of reoperation, although the actual incidence of reoperation is unknown. Causes of reoperation with open repair include graft infection, pseudoaneurysm formation at suture lines, ongoing aortic aneurysmal disease, intercostal patch aneurysms, and the dreaded complication of aortic-enteric fistulas. The durability and long-term complication rate of thoracic endografts are yet to be determined. Recent publications have cautioned that late aortic complications do develop with thoracic endografts.25,26 What is not clear is the acceptable frequency of reintervention with endografting. Reinterventions in the endograft group might be for reasons similar to those for open surgical repair or a new set of complications. In this study there were no reinterventions required in the open surgical group and 3 reinterventions in the endovascular group through 2 years of follow-up. As our knowledge of the nuances of endografting increases, along with technical improvements in graft design and delivery, it will be of interest to see whether the late complication rate will decrease.
There was no difference in overall survival between the 2 cohorts through 2 years of follow-up (Figure 1). There was one late aneurysm-related death (graft infection requiring conversion to open repair) in the endovascular group, and no late aneurysm-related deaths in the open surgical group. There were no aortic ruptures in either population.
Limitations of the Study
The main limitation of the study is that the groups were not randomized. In addition, 2-year follow-up was available in only 77% of the open surgical control cohort and 86% of the endograft cohort. DTAs are a slow-growing and indolent process. Until we have long-term follow-up data, it is difficult to know whether endografting has improved the natural history of these patients. This study was limited to a low-risk group of patients with isolated DTAs, and results might not be applicable to other pathologies for which endografting can be used.
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Conclusions |
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As technology continues to improve and we as surgeons progress along the learning curve, the long-term complications of endografting might or might not be mitigated. Therefore continued vigilant surveillance of patients treated with endovascular repair is important.
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Appendix |
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| See related editorial on page 285.
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Footnotes |
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Joseph Bavaria, Michel Makaroun, Joel Verter, Zi-Fan Yu, and Scott Mitchell report consulting fees from W. L. Gore. Joseph Bavaria and Michel Makaroun report grant support from W. L. Gore.
Read at the Eighty-fifth Annual Meeting of The American Association for Thoracic Surgery, San Francisco, Calif, April 10-13, 2005.
* See Appendix A 
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 E. H. Murphy, A. W. Beck, G. P. Clagett, J. M. DiMaio, M. E. Jessen, and F. R. Arko Combined Aortic Debranching and Thoracic Endovascular Aneurysm Repair (TEVAR) Effective but at a Cost Arch Surg, March 1, 2009; 144(3): 222 - 227. [Abstract] [Full Text] [PDF]
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T. M. Tadros, M. D. Klein, and O. M. Shapira Ascending Aortic Dilatation Associated With Bicuspid Aortic Valve: Pathophysiology, Molecular Biology, and Clinical Implications Circulation, February 17, 2009; 119(6): 880 - 890. [Full Text] [PDF]
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J. L. Martinez Trabal, J. P. Pigott, and A. J. Comerota Use of the Abdominal Aorta as an Alternative Access Site for Thoracic Aortic Stent Graft Placement Vascular and Endovascular Surgery, January 1, 2009; 42(6): 574 - 578. [Abstract] [PDF]
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R. J. Feezor, T. D. Martin, P. J. Hess Jr, M. J. Daniels, T. M. Beaver, C. T. Klodell, and W. A. Lee Extent of Aortic Coverage and Incidence of Spinal Cord Ischemia After Thoracic Endovascular Aneurysm Repair Ann. Thorac. Surg., December 1, 2008; 86(6): 1809 - 1814. [Abstract] [Full Text] [PDF]
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G. C. Hughes, C. F. Sulzer, R. L. McCann, and M. Swaminathan Endovascular Approaches to Complex Thoracic Aortic Disease Seminars in Cardiothoracic and Vascular Anesthesia, December 1, 2008; 12(4): 298 - 319. [Abstract] [PDF]
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G. C. Hughes, M. A. Daneshmand, M. Swaminathan, J. J. Nienaber, E. L. Bush, A. H. Husain, W. G. Wolfe, and R. L. McCann "Real World" Thoracic Endografting: Results With the Gore TAG Device 2 Years After U.S. FDA Approval Ann. Thorac. Surg., November 1, 2008; 86(5): 1530 - 1538. [Abstract] [Full Text] [PDF]
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M. D. Peterson, G. H. Wheatley III, J. Kpodonu, J. P. Williams, V. G. Ramaiah, J. A. Rodriguez-Lopez, and E. B. Diethrich Treatment of type II endoleaks associated with left subclavian artery coverage during thoracic aortic stent grafting. J. Thorac. Cardiovasc. Surg., November 1, 2008; 136(5): 1193 - 1199. [Abstract] [Full Text] [PDF]
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 M. J. Bean, P. T. Johnson, G. S. Roseborough, J. H. Black, and E. K. Fishman Thoracic Aortic Stent-Grafts: Utility of Multidetector CT for Pre- and Postprocedure Evaluation1 RadioGraphics, November 1, 2008; 28(7): 1835 - 1851. [Abstract] [Full Text] [PDF]
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G. Melissano, L. Bertoglio, A. Kahlberg, D. Baccellieri, M. M. Marrocco-Trischitta, F. Calliari, and R. Chiesa Evaluation of a new disease-specific endovascular device for type B aortic dissection. J. Thorac. Cardiovasc. Surg., October 1, 2008; 136(4): 1012 - 1018. [Abstract] [Full Text] [PDF]
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R. K. Greenberg, Q. Lu, E. E. Roselli, L. G. Svensson, M. C. Moon, A. V. Hernandez, J. Dowdall, M. Cury, C. Francis, K. Pfaff, et al. Contemporary Analysis of Descending Thoracic and Thoracoabdominal Aneurysm Repair: A Comparison of Endovascular and Open Techniques Circulation, August 19, 2008; 118(8): 808 - 817. [Abstract] [Full Text] [PDF]
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H. J. Patel and G. M. Deeb Ascending and Arch Aorta: Pathology, Natural History, and Treatment Circulation, July 8, 2008; 118(2): 188 - 195. [Full Text] [PDF]
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G. C. Hughes, J. J. Nienaber, E. L. Bush, M. A. Daneshmand, and R. L. McCann Use of custom Dacron branch grafts for "hybrid" aortic debranching during endovascular repair of thoracic and thoracoabdominal aortic aneurysms J. Thorac. Cardiovasc. Surg., July 1, 2008; 136(1): 21 - 28. [Abstract] [Full Text] [PDF]
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C. Probst, B. Esmailzadeh, W. Schiller, and K. Wilhelm Emergent antegrade endovascular stent placement in a patient with perforated Stanford B dissection via right axillary artery Eur J Cardiothorac Surg, June 1, 2008; 33(6): 1148 - 1149. [Abstract] [Full Text] [PDF]
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H. J. Patel, D. M. Williams, G. R. Upchurch Jr, N. L. Dasika, M. C. Passow, R. L. Prager, and G. M. Deeb A Comparison of Open and Endovascular Descending Thoracic Aortic Repair in Patients Older Than 75 Years of Age Ann. Thorac. Surg., May 1, 2008; 85(5): 1597 - 1604. [Abstract] [Full Text] [PDF]
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H. J. Patel Invited Commentary Ann. Thorac. Surg., May 1, 2008; 85(5): 1612 - 1613. [Full Text] [PDF]
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A. Khoynezhad, C. E. Donayre, J. Smith, G. E. Kopchok, I. Walot, and R. A. White Risk factors for early and late mortality after thoracic endovascular aortic repair. J. Thorac. Cardiovasc. Surg., May 1, 2008; 135(5): 1103 - 1109.e4. [Abstract] [Full Text] [PDF]
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J. Kpodonu, G. H. Wheatley III, J. P. Williams, J. A. Rodriguez-Lopez, V. G. Ramaiah, and E. B. Diethrich A Novel Approach for the Endovascular Repair of the Small Thoracic Aorta: Customizing Off-the-Shelf Endoluminal Grafts to Treat a Post-Coarctation Pseudoaneurysm Ann. Thorac. Surg., March 1, 2008; 85(3): 1115 - 1117. [Abstract] [Full Text] [PDF]
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M. F. Conrad and R. P. Cambria Contemporary Management of Descending Thoracic and Thoracoabdominal Aortic Aneurysms: Endovascular Versus Open Circulation, February 12, 2008; 117(6): 841 - 852. [Full Text] [PDF]
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L. G. Svensson, N. T. Kouchoukos, D. C. Miller, J. E. Bavaria, J. S. Coselli, M. A. Curi, H. Eggebrecht, J. A. Elefteriades, R. Erbel, T. G. Gleason, et al. Expert Consensus Document on the Treatment of Descending Thoracic Aortic Disease Using Endovascular Stent-Grafts Ann. Thorac. Surg., January 1, 2008; 85(1_Supplement): S1 - S41. [Abstract] [Full Text] [PDF]
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 H. Shennib, M. Turina, V. G. Ramaiah, J. Rodriguez-Lopez, G. Wheatley III, J. Kpodonu, and E. Diethrich Endovascular grafts for thoracic aortic pathologies MMCTS, January 1, 2008; 2008(0523): mmcts.2007.003095 - mmcts.2007.003095. [Abstract] [Full Text] [PDF]
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I. Vendramin, G. Piccoli, D. Gasparini, and U. Livi Right minithoracotomy as an alternative approach for endovascular repair of thoracic aortic aneurysm. J. Thorac. Cardiovasc. Surg., December 1, 2007; 134(6): 1589 - 1591. [Full Text] [PDF]
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S. Mohammadi, E. Dumont, P. Voisine, and F. Dagenais Operative strategy for open surgery after failed thoracic aortic stent grafting. J. Thorac. Cardiovasc. Surg., October 1, 2007; 134(4): 1044 - 1046. [Full Text] [PDF]
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S. W. Cheng Endovascular Aortic Stent Grafting for Thoracic Diseases: Current Status Asian Cardiovasc Thorac Ann, August 1, 2007; 15(4): 275 - 277. [Full Text] [PDF]
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 T. G. Gleason and L. C. Benjamin Conventional Open Repair of Descending Thoracic Aortic Aneurysms Perspectives in Vascular Surgery and Endovascular Therapy, June 1, 2007; 19(2): 110 - 121. [Abstract] [PDF]
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W. Y. Szeto and J. E. Bavaria Commentary on "Conventional Open Repair of Descending Thoracic Aortic Aneurysms" Perspectives in Vascular Surgery and Endovascular Therapy, June 1, 2007; 19(2): 122 - 123. [PDF]
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M. R. Go, J.-S. Cho, and M. S. Makaroun Mid-term Results of a Multicenter Study of Thoracic Endovascular Aneurysm Repair Versus Open Repair Perspectives in Vascular Surgery and Endovascular Therapy, June 1, 2007; 19(2): 124 - 130. [Abstract] [PDF]
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E. Y. Woo and J. P. Carpenter Commentary on "Mid-term Results of a Multicenter Study of Thoracic Endovascular Aneurysm Repair Versus Open Repair" Perspectives in Vascular Surgery and Endovascular Therapy, June 1, 2007; 19(2): 131 - 133. [PDF]
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