Mount Sinai’s results for patients undergoing thoracic aortic surgery are unmatched for this high-risk condition by all but the most selective referral centers in the United States. In a 2006 series of 100 consecutive open resections of descending thoracic and thoracoabdominal aortic aneurysms at Mount Sinai, in-hospital mortality was 6 percent and postsurgical paraplegia was 2 percent.1 In a 2007 report, patients undergoing aortic arch surgery at Mount Sinai had a mortality rate of 4.7 percent and a stroke rate of 4.1 percent.2 In another 2007 report of 275 patients with aortic aneurysms or dissections undergoing Bentall procedure (including emergencies), the mortality rate reported was 6 percent and stroke rate 1.5 percent.3 The Bentall procedure involves composite graft replacement of the ascending aorta and aortic valves. For elective Bentall procedures in patients younger than 65 years, the mortality rate was well below 1 percent.4
The potential advantages of an endovascular approach to these aneurysms compared with an open approach include reduced blood loss, faster recovery, and the ability to perform the repair under local or regional anesthesia. The first reported thoracic endovascular aneurysm repair (TEVAR) of a descending thoracic aneurysm occurred in 1994.5 Mount Sinai has been at the forefront of the search for less-invasive alternatives to open surgery, 6 7 and 160 TEVAR procedures have been performed here in the past 9 years.
The results are impressive, with a 94 percent rate of technical success at delivery of the prosthesis and exclusion of the aneurysm. The assisted primary success rate was 96.6 percent. The median length of hospital was three days. The 30-day mortality rate for all cases was 3.3 percent and 1.8 percent for elective (as opposed to emergent) procedures. Spinal cord ischemia occurred in 3.75 percent; however, most of these patients had undergone previous vascular procedures. To facilitate the endovascular repair of aneurysms, adjunctive open surgery was employed in approximately 10 percent of cases, another 10 percent required carotid-subclavian bypass to cover the subclavian artery with the prosthesis, and a similar proportion had surgical conduits for device delivery.
1Etz CD, Halstead JC, Spielvogel D, et al. Thoracic and thoracoabdominal aneurysm repair; is reimplantation of spinal cord arteries a waste of time? Ann Thorac Surg. 2006;82:1670-1677.
2Spielvogel D, Etz CD, Silovitz D, et al. Aortic arch replacement with a trifurcated graft. Ann Thorac Surg. 2007;83:S791-S795.
3Etz CD, Homann TM, Rane N, et al. Aortic root reconstruction with a bioprosthetic valved conduit; a consecutive series of 275 procedures. J Thorac Cardiovasc Surg. 2007;133:1455-1463.
4Hagl C, Strauch TJ, Spielvogel D, et al. Is the Bentall procedure for ascending aorta or aortic valve replacement the best approach for long-term event-free survival? Ann Thorac Surg. 2003;76:698-703.
5Dake MD, Miller DC, Semba CP, et al. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med. 1994;331:1729-1734.
6Ellozy SH, Carroccio A, Minor M, et al. Challenges of endovascular tube graft repair of thoracic aortic aneurysm; midterm follow-up and lessons learned. J Vasc Surg. 2003;38:676-683.
7Carroccio A, Spielvogel D, Ellozy SH, et al. Aortic arch and descending thoracic aortic aneurysms: experience with stent grafting for second-stage “elephant trunk” repair. Vascular. 2005;13:5-10.
Aortic Aneurysm Program