Comparisons Between Thoracic Stent Grafts — How Do We Know Which Stent Graft to Select?

Author:Mustafa Halawa, MD, Benjamin Patterson, MD, Peter Holt, MD, Matt Thompson, MD, Ian M. Loftus, MD

Abstract

Thoracic aortic pathology confers specific challenges to stent graft design and performance. The indications for endovascular intervention are expanding, and the complexity of cases is increasing. Graft design has evolved, and several new iterations of endografts have been introduced into clinical practice. While most devices are probably suitable for straightforward cases, extra care should be exercised in device selection for complex pathology. The assessment of these new grafts is difficult, due to the changing indications for their use and a lack of large-scale clinical trials. Although clinical trials provide the highest level of evidence, they often utilize strict anatomical criteria for inclusion and may not be representative of clinical practice. Despite their inherent shortcomings, multicenter registry data offer a good opportunity for evaluating new endovascular grafts and techniques, as large numbers of cases can be collected in relatively short periods of time.

Introduction

Endovascular repair of thoracic aortic pathology has gained support due to evidence from registries demonstrating acceptable operative mortality and paraplegia rates.1,2 The United States Food and Drug Administration (FDA) approved the commercial use of thoracic endografts in the treatment of thoracic aortic aneurysms (TAA) in 2005.3 Since then, several trials have shown endovascular repair to be a safe and effective alternative to open surgery, with clear outcome benefits.4–6

In comparison with earlier devices, the latest generation of stent grafts have improved the ease of use and reliability, but the question of the long-term durability of endografts remains unanswered. This may be addressed by the analysis of registries that have been created at the request of advisory bodies such as the National Institute for Health and Clinical Excellence in the United Kingdom. Organizations such as these have had particular interest in this technology, as the cost of development has been significant and the current market cost of the devices remains a major consideration in a healthcare system with limited resources.

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