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The incidence of descending thoracic and thoraco abdominal aortic aneurysms is increasing and constitutes a significant problem in modern healthcare. During the last four decades, open surgical repair has been the only option for patients suffering from this pathology. Unfortunately, the outcome of these maximal invasive procedures is associated with high morbidity and mortality.
During the last 15 years, endovascular and hybrid procedures (Figs. 1-2) have been introduced in order to achieve better outcome, however, clinical results are still far from optimal.
Before choosing the best treatment for the patient it is important to emphasize the following issues:
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What is the underlying pathology (Marfan, atherosclerosis, post-dissection)?
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What is the type of morphology (local, extensive, side-branches, kinked, stenosed, calcified)?
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Did the patient undergo previous open or endovascular procedures?
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What about co-morbidity (cardiac, pulmonary, renal, obese)?
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What is the age of the patient?
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What is the experience in open surgery, hybrid procedures, endovascular of the local team?
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How is the local infrastructure organized?
As in all surgical procedures, clinical outcome is related to local experience indicating that high volume hospitals have significantly better results. In addition, adjunctive measures to optimize surgical outcome should be included in the operative protocol.
At present, open surgical repair of complex descending and thoraco abdominal aortic aneurysms should include extra corporeal circulation with selective organ perfusion in order to prevent visceral, renal and spinal cord damage (Fig 3). Furthermore, cerebro spinal fluid drainage and neuromonitoring (Fig 4) can significantly reduce the incidence of spinal cord injuries.
Hybrid procedures are actually a combination of open and endovascular techniques. Visceral and renal artery debranching is followed by endovascular coverage of the thoracic and abdominal aorta.
Total endovascular repair follows the principle of implanting an endograft which has holes and fenestrations to accommodate side branches to revascularize the visceral and renal arteries. It comprises a complex and expensive technology which definitely will dictate future aneurysm treatment.
The main task is to choose the best treatment for the patient. The “ideal menu-card” comprises the three above mentioned surgical and endovascular options and it should therefore always be a tailor made or custom made approach. In that difficult decision it is important that young patients and patients suffering from connective tissue disease receive the best treatment, which is at present an open surgical procedure. Older patients, especially when suffering from cardiac, pulmonary, renal or other general diseases can be considered for either a hybrid or endovascular solution.
The main statements include:
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Open repair of thoraco abdominal aortic aneurysms (TAAA) is still the gold standard in young and Marfan patients
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Open repair requires an extensive surgical protocol, including extra corporeal circulation and neuromonitoring
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Endovascular repair for TAAA will determine the near future but requires technical innovation
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Open and endovascular repair should be centralized in high volume institutes and performed by dedicated multidisciplinary teams.
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