This document reviews endovascular repair (TEVAR) for ruptured thoracic aortic aneurysms. It provides data on the incidence, mortality rates, and management of ruptured thoracic aneurysms. Open surgical intervention has mortality rates of 18-27% while TEVAR has shown lower 30-day mortality rates of 11-17% in single-institution studies. However, TEVAR is associated with higher mortality risks in older patients (>75 years old) and those with hemodynamic instability. The document recommends TEVAR as a less invasive alternative to open surgery for ruptured thoracic aneurysms, particularly when performed at experienced centers.

1. TEVAR for the RupturedTEVAR for the Ruptured
AneurysmsAneurysms
Jamal J. Hoballah MD, MBA, FACSJamal J. Hoballah MD, MBA, FACS
Professor and ChairmanProfessor and Chairman
Department of SurgeryDepartment of Surgery
American University of BeirutAmerican University of Beirut
14th Congress of Asian Society for Vascular Surgery & 8th Asian Venous Forum14th Congress of Asian Society for Vascular Surgery & 8th Asian Venous Forum
16thCongress of Turkish Society for Vascular and Endovascular Surgery16thCongress of Turkish Society for Vascular and Endovascular Surgery

2. ObjectivesObjectives
• Review available data on TEVARReview available data on TEVAR
for Ruptured Thoracic Aneurysmsfor Ruptured Thoracic Aneurysms
• Recommendations for successfulRecommendations for successful
Emergency TEVAR programEmergency TEVAR program

3. Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic Aneurysms
Scope of the problemScope of the problem
Incidence:Incidence: 5/100,0005/100,000
Ascending & ArchAscending & Arch 70%70%
Descending AortaDescending Aorta 30%30%
Johansson et al JVS 1995Johansson et al JVS 1995

4. Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic Aneurysms
ICD 9 cm Cases/ year
2011
Thoracic Aneurysm 7601
Ruptured Thoracic
Aneurysm
798
Abdominal Aortic
Aneurysm
43466
Ruptured AAA 5023
2011 Nationwide In Patient Sample Data
US Department of Health & Human Services
TAA : 7 times less than AAA
TAA Rupture: 7 times less than Ruptured AAA

5. Ruptured Thoracic AorticRuptured Thoracic Aortic
AneurysmsAneurysms
ICD 9 cm Mortality Routine
Discharge
Home
health
care
Short term
hospital/
Rehab center/
nursing home
Ruptured
Thoracic
Aneurysm
37% 15% 12% 36%
2011 Nationwide In Patient Sample Data
US Department of Health & Human Services

6. Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic Aneurysms
Heterogeneous PathologyHeterogeneous Pathology
LocationLocation
• Ascending AortaAscending Aorta
• Aortic ArchAortic Arch
• Descending AortaDescending Aorta
• Thoraco-Abdominal AortaThoraco-Abdominal Aorta

7. Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic Aneurysms
Heterogeneous PathologyHeterogeneous Pathology
EtiologyEtiology
• Degenerative Thoracic AneurysmDegenerative Thoracic Aneurysm
• Traumatic blunt injury PseudoaneurysmTraumatic blunt injury Pseudoaneurysm
• Complicated Dissection ( Acute or Chronic)Complicated Dissection ( Acute or Chronic)
• Miscellaneous ( Mycotic)Miscellaneous ( Mycotic)

12. Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic Aneurysms
Heterogeneous PathologyHeterogeneous Pathology
PresentationPresentation
UnstableUnstable
Stable/ Contained ruptureStable/ Contained rupture

13. Ruptured Thoracic Aortic Aneurysms:Ruptured Thoracic Aortic Aneurysms:
ManagementManagement
• Open Surgical InterventionOpen Surgical Intervention
• TEVARTEVAR
– Chimney/ SnorkelChimney/ Snorkel
– Hybrid Approach (Debranching)Hybrid Approach (Debranching)

14. Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic Aneurysms
Open Surgical InterventionOpen Surgical Intervention
• Traditional approachTraditional approach
• Requires thoracic surgical expertiseRequires thoracic surgical expertise
• Limited Thoracic CentersLimited Thoracic Centers
• Techniques:Techniques:
– Clamp and sewClamp and sew
– Heart lung Machine; Left Heart BypassHeart lung Machine; Left Heart Bypass
– Deep hypothermic circulatory arrestDeep hypothermic circulatory arrest

15. Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic Aneurysms
Open Surgical InterventionOpen Surgical Intervention
Contemporary ResultsContemporary Results
Mortality rate: 18- 27%Mortality rate: 18- 27%
Girardi et al Ann Thorac Surg 2002Girardi et al Ann Thorac Surg 2002
Barbato et al JVS 2007Barbato et al JVS 2007

16. Population-based outcomes ofPopulation-based outcomes of
open descending thoracic aorticopen descending thoracic aortic
aneurysm repairaneurysm repair
Schermerhorn ML et alSchermerhorn ML et al J Vasc Surg 2008 Oct.J Vasc Surg 2008 Oct.
2549 patients Mortality rate
Entire group
Age>75
Intact 10% 17.6%
Ruptured 45% 52%

17. TEVAR for Ruptured ThoracicTEVAR for Ruptured Thoracic
Aortic AneurysmsAortic Aneurysms
• First EVAR for ruptured AAA reported in 1994First EVAR for ruptured AAA reported in 1994
– Yusuf SW, Whitaker SC, Chuter TA, et al.Yusuf SW, Whitaker SC, Chuter TA, et al. Emergency endovascular repairEmergency endovascular repair
of leaking aortic aneurysms. Lancet 1994; 344:of leaking aortic aneurysms. Lancet 1994; 344:1645.1645.
• First TEVAR for ruptured TAA reported in 1997First TEVAR for ruptured TAA reported in 1997
– Semba CP, et al. Acute rupture of the descending thoracic aorta: repairSemba CP, et al. Acute rupture of the descending thoracic aorta: repair
with use of endovascular stent-grafts. J Vasc Interv Radiol 1997;8:337-42with use of endovascular stent-grafts. J Vasc Interv Radiol 1997;8:337-42

18. TEVAR AdvantagesTEVAR Advantages
• Can be provided by experienced Vascular or CardioCan be provided by experienced Vascular or Cardio
Thoracic SurgeonsThoracic Surgeons
• Can be provided at non cardiac surgery centersCan be provided at non cardiac surgery centers
• Increase availability of expertise capable of dealing withIncrease availability of expertise capable of dealing with
the problemthe problem
• Still needs Cardio Thoracic Surgery back upStill needs Cardio Thoracic Surgery back up

19. TEVAR for Ruptured Thoracic AneurysmsTEVAR for Ruptured Thoracic Aneurysms
Available DataAvailable Data
• Case reportsCase reports
• Single Institution ExperienceSingle Institution Experience
• Multi Institution ExperienceMulti Institution Experience
• Meta analysis studiesMeta analysis studies
• Nationwide Data baseNationwide Data base

20. Endovascular stent-graft placement for acuteEndovascular stent-graft placement for acute
and contained rupture of the descendingand contained rupture of the descending
thoracic aorta.thoracic aorta.
• 17 patients; July 1999 - November 2004,17 patients; July 1999 - November 2004,
• Rupture due to:Rupture due to:
• Thoracic Aortic Aneurysm TAA n=6Thoracic Aortic Aneurysm TAA n=6
• Acute aortic dissection AAD, n=6Acute aortic dissection AAD, n=6
Penetrating aortic ulcer PAU, n=3Penetrating aortic ulcer PAU, n=3
• Blunt chest trauma n=2Blunt chest trauma n=2
– Eggebrecht at alEggebrecht at al Catheter Cardiovasc Interv.Catheter Cardiovasc Interv. 2005 Dec2005 Dec

21. Endovascular stent-graft placement for acuteEndovascular stent-graft placement for acute
and contained rupture of the descendingand contained rupture of the descending
thoracic aorta.thoracic aorta.
• Technical feasibility 100%Technical feasibility 100%
• Complete exclusion 65%Complete exclusion 65%
• 30 day mortality 24%30 day mortality 24%
• 1 yr survival 52%1 yr survival 52%
• 3 yr survival 52%3 yr survival 52%
– Eggebrecht at alEggebrecht at al Catheter Cardiovasc Interv.Catheter Cardiovasc Interv. 2005 Dec2005 Dec

22. Endovascular stent-graft placement forEndovascular stent-graft placement for
acute and contained rupture of theacute and contained rupture of the
descending thoracic aortadescending thoracic aorta
Pre-procedural determinants of mortalityPre-procedural determinants of mortality
• Etiology of rupture TAA or AAD (P=0.024)Etiology of rupture TAA or AAD (P=0.024)
• Maximum aortic diameter>5 cm (P=0.024)Maximum aortic diameter>5 cm (P=0.024)
• Presence of mediastinal hematoma (P=0.056)Presence of mediastinal hematoma (P=0.056)
• Estimated lesion length requiring >1 stent-graftEstimated lesion length requiring >1 stent-graft
to be covered (P=0.009to be covered (P=0.009
– Eggebrecht at alEggebrecht at al Catheter Cardiovasc Interv.Catheter Cardiovasc Interv. 2005 Dec2005 Dec

23. Endovascular stent-graft placement for acuteEndovascular stent-graft placement for acute
and contained rupture of the descendingand contained rupture of the descending
thoracic aorta.thoracic aorta.
Post-procedural determinants of mortalityPost-procedural determinants of mortality
• residual leakage at the conclusion (P=0.009),residual leakage at the conclusion (P=0.009),
• postprocedural need for dialysis (P=0.004),postprocedural need for dialysis (P=0.004),
• prolonged ventilation (P=0.043)prolonged ventilation (P=0.043)
– Eggebrecht at alEggebrecht at al Catheter Cardiovasc Interv.Catheter Cardiovasc Interv. 2005 Dec2005 Dec

24. A comparative analysis of open andA comparative analysis of open and
endovascular repair for the ruptured descendingendovascular repair for the ruptured descending
thoracic aorta.thoracic aorta.
Single Institution ( University of Michigan)Single Institution ( University of Michigan)
• TEVAR: Older patientsTEVAR: Older patients
• Independent predictors of early mortality, stroke,Independent predictors of early mortality, stroke,
permanent spinal cord ischemiapermanent spinal cord ischemia
– Hemodynamic instabilityHemodynamic instability
– Open repairOpen repair
Patel et al J Vasc Surg. 2009 DePatel et al J Vasc Surg. 2009 Decc
TEVAR OPEN
Patients: 69 35 34
Mortality % 11 26

25. Open surgery versus endovascular repair ofOpen surgery versus endovascular repair of
ruptured thoracic aortic aneurysms.ruptured thoracic aortic aneurysms.
..
• 161 patients at 7 Institutions161 patients at 7 Institutions
• Risk factor for composite event :Risk factor for composite event :
– Increasing ageIncreasing age
– HypotensionHypotension
Jonker et alJonker et al J Vasc Surg.J Vasc Surg. 2011 May2011 May
TEVAR OPEN
Patients 92 69
Mortality 30 day% 17 24
Composite mortality , stroke
paraplegia%
21 36
4 yr survival % 75 64

26. Endovascular repair of ruptured thoracic aorticEndovascular repair of ruptured thoracic aortic
aneurysms.aneurysms.
..
• 92 TEVAR patients at 7 Institutions92 TEVAR patients at 7 Institutions
• Jonker et al EurJonker et al Eur J EndoVasc Surg.J EndoVasc Surg. 20112011
<75yrs >75yrs
Patients 67 25
Mortality 30 day% 13.4 32
Postoperative stroke% 1.5 24
2 yr survival % 84 52

27. Meta-analysis of open versus endovascularMeta-analysis of open versus endovascular
repair for ruptured descending thoracic aorticrepair for ruptured descending thoracic aortic
aneurysmaneurysm
• 28 studies; 224 patients;28 studies; 224 patients;
– Jonker FH et al, J Vasc Surg.Jonker FH et al, J Vasc Surg. 2010 Apr2010 Apr
TEVAR Open Repair
Patients 143 (63.2%) 81 (36.2%)
30 d Mortality 18.9% 33.3%
Myocardial Infarction 3.5% 11.1%
Stroke 4.1% 10%
Paraplegia 3.1% 5.5%
Additional Vascular Intervention 9.1% 2.3%
3 yr Aneurysm related survival 70.6% unavailable

28. Endovascular versus open repair of rupturedEndovascular versus open repair of ruptured
descending thoracic aortic aneurysms: adescending thoracic aortic aneurysms: a
nationwide risk-adjusted study of 923 patients.nationwide risk-adjusted study of 923 patients.
• 923 between 2006-2008923 between 2006-2008
• TEVAR 39% OTR 60%TEVAR 39% OTR 60%
• Mortality Rate; TEVAR :23% Open: 28%Mortality Rate; TEVAR :23% Open: 28%
• Odds of mortality , complications and failure toOdds of mortality , complications and failure to
rescue:rescue: comparablecomparable
• TEVAR 3X higher odds of routine dischargeTEVAR 3X higher odds of routine discharge
– Gopaldas RR et al J Thorac Cardiovasc Surg.Gopaldas RR et al J Thorac Cardiovasc Surg. 20112011

29. Endovascular versus open repair of rupturedEndovascular versus open repair of ruptured
descending thoracic aortic aneurysms: adescending thoracic aortic aneurysms: a
nationwide risk-adjusted study of 923 patients.nationwide risk-adjusted study of 923 patients.
Smaller hospitals:Smaller hospitals:
• Lower mortality rate for TEVAR vs Open repairLower mortality rate for TEVAR vs Open repair
Smaller hospital vs Larger HospitalSmaller hospital vs Larger Hospital
• Mortality, complication , failure to rescueMortality, complication , failure to rescue
– TEVAR : comparableTEVAR : comparable
– Open repair : higherOpen repair : higher
• Gopaldas RR et al J Thorac Cardiovasc Surg.Gopaldas RR et al J Thorac Cardiovasc Surg. 20112011

30. Endovascular versus open repair of rupturedEndovascular versus open repair of ruptured
descending thoracic aortic aneurysms: adescending thoracic aortic aneurysms: a
nationwide risk-adjusted study of 923 patients.nationwide risk-adjusted study of 923 patients.
TEVARTEVAR
• May be an ideal alternative to OAR for ruptured descendingMay be an ideal alternative to OAR for ruptured descending
thoracic aortic aneurysmthoracic aortic aneurysm
• Particularly in small hospitals where expertise in OAR mayParticularly in small hospitals where expertise in OAR may
be lackingbe lacking
– Gopaldas RR et al J Thorac Cardiovasc Surg.Gopaldas RR et al J Thorac Cardiovasc Surg. 20112011

31. Meta-analysis of endovascular vs open repair forMeta-analysis of endovascular vs open repair for
traumatic descending thoracic aortic rupture.traumatic descending thoracic aortic rupture.
• 17 studies17 studies
• 589 patients; 369 Open 220 TEVAR589 patients; 369 Open 220 TEVAR
• TEVAR Lower 30 day mortality ODD ratio 0.44TEVAR Lower 30 day mortality ODD ratio 0.44
• TEVAR Lower Procedure related mortality ODDTEVAR Lower Procedure related mortality ODD
Ratio 0.31Ratio 0.31
– Xenos ES et al, J Vasc Surg 2008 NovXenos ES et al, J Vasc Surg 2008 Nov

32. Tends and Outcomes of endovascular and openTends and Outcomes of endovascular and open
treatment for traumatic thoracic aortic injurytreatment for traumatic thoracic aortic injury
New York State SPARCS data base 2000-20007New York State SPARCS data base 2000-20007
328 patients; Open 80% TEVAR 20%328 patients; Open 80% TEVAR 20%
• TEVAR rates exceeded Open as of 2006TEVAR rates exceeded Open as of 2006
• TEVAR lower mortality rate and post operativeTEVAR lower mortality rate and post operative
pulmonary complicationspulmonary complications
• No difference in cardiac complication, renalNo difference in cardiac complication, renal
failure, stroke or paraplegiafailure, stroke or paraplegia
• TEVAR device related complications 9%TEVAR device related complications 9%
– Jonker et al, J Vasc Surg 2010 MarchJonker et al, J Vasc Surg 2010 March

33. Update on blunt thoracic aortic injury: fifteen-yearUpdate on blunt thoracic aortic injury: fifteen-year
single-institution experiencesingle-institution experience
• Level I Trauma Center 1997-2012Level I Trauma Center 1997-2012
– Estrera et alEstrera et al J Thorac Cardiovasc Surg 2013 March.J Thorac Cardiovasc Surg 2013 March.
TEVAR Open repair distal
perfusion
Open repair
Cross clamp
patients 69 77 29
Early Mortality 4% 14% 31%
I yr survival 92% 76% 76%
5 yr survival 87% 75% 75%

34. Expanding TEVAR into Ascending and ArchExpanding TEVAR into Ascending and Arch
Aortic RupturesAortic Ruptures
• TTotal endovascular repair of acute ascendingotal endovascular repair of acute ascending
aortic rupture: a case report and review of theaortic rupture: a case report and review of the
literatureliterature
– McCallum JCMcCallum JC Vasc Endovascular Surg.Vasc Endovascular Surg. 2013 Jul2013 Jul
• Emergency One-Stage Hybrid Surgery forEmergency One-Stage Hybrid Surgery for
Ruptured Aneurysm of the Distal Aortic ArchRuptured Aneurysm of the Distal Aortic Arch
– Kim et al Tex Heart Inst J. 2013Kim et al Tex Heart Inst J. 2013

35. TEVAR for Ruptured Thoracic AneurysmsTEVAR for Ruptured Thoracic Aneurysms
SummarySummary
• Successful Delivery: >95%Successful Delivery: >95%
• Very Low rate of conversion to openVery Low rate of conversion to open
• Mortality rate 30 days : 12-15%Mortality rate 30 days : 12-15%
– Traumatic:Traumatic: 5%5%
– Degenerative >75 yr:Degenerative >75 yr: 32%32%
• Morbidity rate lower than openMorbidity rate lower than open
• Reintervention may be neededReintervention may be needed
• Acceptable 1-4 yr follow upAcceptable 1-4 yr follow up
• Can be Safely done at smaller hospitalsCan be Safely done at smaller hospitals

36. TEVAR for Ruptured Thoracic AneurysmsTEVAR for Ruptured Thoracic Aneurysms
Recommendations for SuccessRecommendations for Success
• Establish a team ( Vascular / Thoracic /Interventional)Establish a team ( Vascular / Thoracic /Interventional)
• Develop Your protocolDevelop Your protocol
• Plan a Hybrid OR suitePlan a Hybrid OR suite
• Graft InventoryGraft Inventory
• Preoperative CT 1mm imaging to include pelvisPreoperative CT 1mm imaging to include pelvis
• Large Sheaths/ Possible need for iliac conduitsLarge Sheaths/ Possible need for iliac conduits
• Coverage of subclavian or celiac/ debranchingCoverage of subclavian or celiac/ debranching
• CSF DrainageCSF Drainage
• Case selectionCase selection

46. TEVAR for Ruptured Thoracic AneurysmsTEVAR for Ruptured Thoracic Aneurysms
Into the FutureInto the Future
• Here to stayHere to stay
• Hybrid Approach to include Ascending andHybrid Approach to include Ascending and
Arch aneurysms rupturesArch aneurysms ruptures
• Newer Off the Shelf GraftsNewer Off the Shelf Grafts

49. A multicenter clinical trial of endovascularA multicenter clinical trial of endovascular
stent graft repair of acute catastrophes of thestent graft repair of acute catastrophes of the
descending thoracic aorta.descending thoracic aorta.
59 patients;59 patients;
Dissection: cTBDDissection: cTBD n = 19n = 19
Degenerative: RDADegenerative: RDA n = 20n = 20
Traumatic TT:Traumatic TT: n = 20n = 20
– Cambria et alCambria et al J Vasc Surg.J Vasc Surg. 2009 Dec2009 Dec
TEVAR Open
30 day Mortality
12% 24%
Mortality or Paraplegia
13.6% 30%

50. A multicenter clinical trial of endovascularA multicenter clinical trial of endovascular
stent graft repair of acute catastrophes of thestent graft repair of acute catastrophes of the
descending thoracic aorta.descending thoracic aorta.
– Cambria et alCambria et al J Vasc Surg.J Vasc Surg. 2009 Dec2009 Dec
At I yr TEVAR
Actuarial survival 66 %
Dissection 79 %
Traumatic 79%
Degenerative 37 %
Conversion 1 patient
Major device related events 2 patients

51. A multicenter clinical trial of endovascularA multicenter clinical trial of endovascular
stent graft repair of acute catastrophes of thestent graft repair of acute catastrophes of the
descending thoracic aorta.descending thoracic aorta.
• TEVAR for thoracic aortic catastrophes hasTEVAR for thoracic aortic catastrophes has
advantages when compared with literature-advantages when compared with literature-
based results of open repair.based results of open repair.
• One-year treatment results indicate a lowOne-year treatment results indicate a low
incidence of graft-related complications.incidence of graft-related complications.
• TEVAR is the preferred initial treatment for theTEVAR is the preferred initial treatment for the
DTA catastrophes.DTA catastrophes.
– Cambria et alCambria et al J Vasc Surg.J Vasc Surg. 2009 Dec2009 Dec