TEVAR: The Transformation Marches On

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The article Review of Current Thoracic Endografts with or Pending FDA Approval by Wang and Milner is a timely current-status report on TEVAR technologies, and constitutes an excellent foundation for this issue’s editorial. While aneurysms and dissections predominate, thoracic aortic pathologies are diverse and of multiple etiologies. Put all together, the total number of patients may approximate, if not surpass, AAA volumes. Surgical repair has been the acknowledged standard of care for a long time. But, while treatment outlook has improved over the past 20 years, largely as a result of advances in perioperative care and refined surgical techniques, dissatisfaction with operative outcomes persists because of continued high morbidity and only borderline-acceptable 30-day mortality rates. Furthermore, the formidable and highly invasive nature of the operation often leads to a prolonged period of difficult and often incomplete postoperative patient recovery. Lastly, and for the same reasons, many patients with potentially life-threatening thoracic aortic diseases are deemed to be “inoperable” and excluded from treatment.

The stage was set, therefore, for the development of less-invasive solutions, propelling endovascular repair to a level of excitement and rapid acceptance seldom, if ever seen in any other cardiovascular area. Even at this early phase and with only one FDA-approved endograft device, TEVAR has already (essentially) replaced open surgical repair for treatment of focal descending thoracic aortic aneurysms (Figure 1) in the majority of patients. The development of these new technologies and strategies has occurred in the space of 10 years or less. Early on, thoracic endograft performance and progress were limited by inadequacies in conception and implementation, as the initial TEVAR efforts were conceived “simply” as extensions or poor adaptations of AAA endografts. It took much clinical experience and focused scrutiny for experts and industry to zero in on the unique characteristics and challenges the thoracic aorta and aortic arch present. Thoracic stent-graft technologies are now (finally) being created to meet such needs. Having said that, it still holds true today that many aspects of the TEVAR field remain unconquered — such as optimal management of arch and visceral branches, and endovascular solutions for the ascending aorta and “total arch” to name but the most obvious. Fortunately, we are finally beginning to understand just what the important questions should be… so answers and solutions can be developed and implemented. The future of TEVAR is undoubtedly bright, with potential to revolutionize the entire field of thoracic aortic surgery. And it will happen in short order!

“Disruptive” and “transformational” are apt terms to describe these developments. We may just be at the beginning of this incredible transformation, and yet, almost everyone today realizes that the impact is, and will be, profound and long lasting. Aortic surgery will never be the same.