Thoracic Endovascular Aortic Repair (TEVAR) Is it a replacement for Open Surgery for Aortic Arch & Descending Aorta?

Abstract

A great controversy remains when comparing open aortic arch repair and hybrid aortic surgery.Many surgeons consider conventionalsurgeries upon the arch as highly morbid procedures that are associated with high mortality rates. In contrary to that belief, arch surgeries have proven by evidence to be safe and effective, with low morbidity and mortality, thanks to the advances achieved in terms of perfusion and surgical techniques. The main factors that stand in the face of surgical aortic arch repair are related to lack of fitness for such major operation, as most patients carry significant morbidities pre-operatively. In the other hand, many aortic surgeons question the concept behind using endoluminal stent-grafts for exclusion of aortic pathology.108, 109 Endovascular interventions are rapidly growing with developments achieved in that field outpacing the available data, and the enthusiasm behind the growth in utilization of such techniques is partly driven by industrial efforts. Yet, evidence has declared encouraging results, especially after the high success rates achieved with abdominal aortic disease.108 Open arch surgery shows lower mortality rates in an era of enhanced cardiothoracic surgical techniques, while it still represents a major operative encounter for highly morbid patients in whom general anaesthesia and the burden of the inflammatory response caused by the heart-lung machine are better to be avoided whenever possible. In such patients, the utilization of a hybrid strategy would prevent the patient from exposure to the hazards of the heart lung machine and deep hypothermia. Yet, open surgery remain the only option for some anatomic extents of the disease where endovascular stent grafting will remain helpless in excluding the diseased segment.109 Great deal of information is lacking, as well as inconsistency of the available data and the lack of an agreed consensus about standardized definitions regarding aortic arch repair and end points, mandate the emergence of expert committees to establish solid guidelines to guide the best practice methods for aortic arch repairs.109 One of these efforts is established as a multicenter project, namely the ARCH project carried out by the International Aortic Arch Surgery Group (IASSG), to evaluate outcomes of aortic arch surgery among 41 arch surgeons from 10 countries. The project aims at achieving a proper consensus with respect to the outcomes of variable surgical techniques in terms of mortality and morbidity, identify pre-operative risk predictors and formulate risk models, as well as attaining databases for mid and long-term outcomes.110