Скачать или смотреть SVS Guidelines: Thoracic endovascular aortic repair

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This Deep Dive outlines the Society for Vascular Surgery’s clinical practice guidelines for Thoracic Endovascular Aortic Repair (TEVAR), a minimally invasive approach that has largely replaced open surgery for descending thoracic aortic diseases due to significantly better patient outcomes.

Key takeaways from the guidelines include:
*Shift to T-VAR:* TEVAR is the preferred method for most elective descending thoracic aortic aneurysms due to lower complications, reduced mortality, and shorter hospital stays, especially when patient anatomy is suitable for the device.
*Diagnostic Imaging:* Fine-cut Computed Tomography Angiography (CTA) of the entire aorta, including iliac and femoral arteries, with 3D centerline reconstruction software, is crucial for precise pre-operative planning. Magnetic Resonance Angiography (MRA) is an alternative for patients with contrast allergies.
*Specific Indications:* For asymptomatic descending thoracic aortic aneurysms, TEVAR is strongly recommended if the diameter exceeds 5.5 cm in low-risk patients. Intramural hematoma (IMH) and penetrating aortic ulcer (PAU) initially warrant close observation and blood pressure control, with TEVAR indicated for progression or complications.
*Risk Mitigation:* Strategies to minimise complications include maintaining controlled hypertension and prophylactic cerebrospinal fluid (CSF) drainage to protect the spinal cord. Left subclavian artery (LSA) revascularisation is often suggested if its coverage is planned. Kidney injury prevention involves minimizing contrast material use with non-ionic, hypo-osmolar agents and using adjuncts like IVUS. Pre-emptive stenting or revascularization of the superior mesenteric artery (SMA) or celiac artery (CA) is recommended if CA coverage is necessary.
*Access & Surveillance:* Ultrasound-guided percutaneous femoral artery access is preferred. Alternative strategies like surgical iliac conduits or "body floss" are used for challenging iliofemoral anatomy. Long-term surveillance with contrast-enhanced CT scans is essential: at one month, 12 months, and then yearly for life, to monitor the repair and detect late complications like endoleaks.

These guidelines offer a vital framework for optimising patient outcomes in this evolving field.