Thoracic Endovascular Aortic Repair in the Setting of Compromised Distal Landing Zones.

Abstract Background To report short- and intermediate-term outcomes of two distinct approaches to thoracic endovascular aortic repair (TEVAR) for descending aortic aneurysms in patients with compromised distal landing zones (CDLZs). Methods 51 patients (38 female, average age 72 ± 9 years) underwent 55 TEVARs (2008-2018) for aneurysmal disease. Inclusion criteria consisted of TEVAR in a CDLZ, defined as: ≥3.5 cm diameter, ≥50% cross-sectional thrombus, or ≥25% circumferential mural calcification in the 2 cm supraceliac aorta, or tortuosity index ≥1.1 over the 10 cm supraceliac aorta. Treatment cohorts were: 1) TEVAR alone (n = 29); 2) TEVAR with adjunct consisting of visceral snorkel graft with distal stent extension (n = 20) and/or EndoAnchors (n = 6). Results Perioperative complication rate was 20%. 30-day mortality was 5% including 1 access-site related intraoperative death and 1 postoperative death from embolic mesenteric ischemia. Median clinical follow-up was 2.2 years. Intermediate-term outcomes include: type 1B endoleaks, 35%; ≥0.5 cm/year maximal aortic diameter growth, 9%; reintervention, 15%; and all-cause mortality, 25%. The distal landing zone diameter increased by 0.3 cm/year in the TEVAR alone however decreased by 0.1 cm/year in the adjunct cohort (p = 0.04). Conclusions TEVAR is a viable alternative for the treatment of thoracoabdominal aortic aneurysms in patients with CDLZs, although these patients may benefit significantly from the development of branched thoracoabdominal devices. In the interim, the use of TEVAR adjuncts may limit progressive degeneration of the distal landing zone in this patient population.