Preface

Article Outline

• Chapters 1 to 4: General overview of TEVAR and descending thoracic aorta trials
• Chapters 5 to 7: Specific alternative pathologies
• Chapters 8 to 11: Imaging and techniques
• Chapters 12 to 14: Debranching
• Chapters 15 to 17: Complications
• Chapters 18 to 20: Skills and coding
• Acknowledgment
• Copyright

Thoracic endovascular aortic repair (TEVAR) is being incorporated into many specialty practices, including vascular surgery, cardiothoracic surgery, interventional radiology, interventional cardiology, and interventional vascular medicine. The Society for Vascular Surgery is committed to helping these physicians learn about this new alternative therapy, which is associated with less morbidity and faster patient recovery. The purpose of this syllabus is to facilitate the safe dissemination of TEVAR into clinical practice; as such, it is designed to supplement continuing medical education-approved procedure training courses, device-specific training, and other educational pathways.

Many skills—cognitive, technical, and organizational—are needed to develop a clinical program of TEVAR. These include experience in the care of patients with thoracic aortic pathology, knowledge of therapeutic options, familiarity with thoracic aortography and other imaging modes, patient and device selection, device deployment, management of large sheath access and aortoiliac injuries, peripheral interventional catheter-based therapies such as selective catheterization and stenting, techniques for extra-anatomic bypass, and recognition and treatment of early and late complications.

This syllabus addresses each skill area in chapters authored by experts in the field, among whom there is a diversity of opinions, techniques, and approaches. This diversity is both appropriate and instructive, since TEVAR is still in the early stages of development. The syllabus itself, likely the first of many that will be needed as the knowledge base broadens, is a first step by the Society for Vascular Surgery into endovascular thoracic coursework.

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Chapters 1 to 4: General overview of TEVAR and descending thoracic aorta trials 

Dr Mark Eskandari, from Northwestern, leads off by outlining the components of an TEVAR center in general terms. Next, Drs James Black, III, and Richard Cambria, from Johns Hopkins Hospital and Massachusetts General Hospital (MGH), review contemporary results with open repair of thoracic aneurysms, comparing the practical realities of population-based data with results at centers of excellence. The University of Pittsburgh group, represented by Drs Jae Sung Cho, Shan-e-ali Haider, and Michel Makaroun, then details the current status of the first three pivotal clinical trials in the United States. Although treatment of descending thoracic aneurysms is the only Food and Drug Administration-approved indication for TEVAR at this time, other pathology has been treated with endografts outside the United States, and Dr Jon Matsumura presents the results of a worldwide survey of practical clinical applications of thoracic endografts.

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Chapters 5 to 7: Specific alternative pathologies 

The second group of chapters focuses on specific aspects of TEVAR for aortic diseases other than elective aneurysm repair, including the repair of traumatic thoracic aortic injuries by Drs Peter Lin, Ruth Bush, Wei Zhou, Eric Peden, and Alan Lumsden from Baylor; the pathophysiology and treatment of aortic dissection by Drs Marvin Atkins, Jr, James Black, III, and Richard Cambria from MGH; and emergency stent-graft treatment, most commonly for rupture, by Dr Mark Farber from University of North Carolina-Chapel Hill. The comprehensive coverage and tabular distillation of the literature in these chapters is distinguishing.

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Chapters 8 to 11: Imaging and techniques 

Technical considerations common to TEVAR are addressed in the next four chapters, starting with Dr Kougias and his colleagues from Baylor who review preoperative imaging and device sizing. They also introduce the concepts of access evaluation and debranching that are covered in detail in later chapters. In the well-illustrated chapter on intraprocedural imaging, Drs Rodney White, Carlos Donayre, Irwin Walot, and George Kopchok discuss techniques for thoracic aortography and intravascular ultrasound and special equipment used in TEVAR. They include a helpful list of specific ancillary supplies that are utilized at Harbor-UCLA Medical Center. Drs Shane Parmer and Jeffrey Carpenter, from the University of Pennsylvania, discuss important techniques for large sheath insertion during TEVAR that may reduce the risk of iliofemoral artery rupture, a common and potentially fatal vascular complication. Dr Mark Morasch, from Northwestern University, winds up with a look at patient selection, strategic approach, and the technical details of percutaneous techniques for aneurysm repair, a method that avoids the femoral cutdown.

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Chapters 12 to 14: Debranching 

The next group of chapters addresses techniques used to treat thoracic pathology near the arch and visceral vessels. Drs Mark Morasch and Brian Peterson detail subclavian artery transposition and bypass techniques that are frequently required during TEVAR. Based on their experience, they advocate for more liberal use of subclavian revascularization. This contrasts with a more conservative approach by Dr Luis Sanchez from Washington University, who also describes extra-anatomic alternatives for managing proximal arch vessels. Dr Farber’s experience completes the debranching options, with indications and techniques for the distal visceral vessels; this chapter discusses the broad and evolving range of creative hybrid procedures.

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Chapters 15 to 17: Complications 

TEVAR is less invasive than standard open surgical techniques but is still associated with significant morbidity. Three chapters deal with postprocedure complications, beginning with an exploration of acute complications. Drs Timothy Sullivan and Thoralf Sundt III from the Mayo Clinic focus on the most devastating neurologic complications—stroke and spinal cord ischemia—including preventive strategies. Postoperative imaging surveillance and endoleak management are covered by Drs William Stavropoulos and Jeffrey Carpenter in a well-illustrated chapter that details the similarities and differences between endoleak management after TEVAR and endovascular aneurysm repair. Other late complications are described by Drs Karthikeshwar Kasirajan, Ross Milner, and Elliot Chaikof from Emory, with the help of excellent photographs and radiographs that explain the multitude of delayed problems that can be expected.

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Chapters 18 to 20: Skills and coding 

In chapter 18, the Emory group outlines the skills that they consider essential for initiating a program. It should be noted that at press-time, formal competency statements were being debated by the relevant professional societies. Dr Gary Seabrook, from the Medical College of Wisconsin, provides a chapter that clearly describes CPT coding for descending thoracic aorta endovascular repair. Dr Tim Chuter, from the University of California, San Francisco, concludes the syllabus with a vision of future directions of thoracic endografts.

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The authors thank the Society for Vascular Surgery for the privilege of contributing to this syllabus and sincerely hope readers find the information useful in starting their own TEVAR programs.