Commentary
Vascular Surgery and
Commentary on “Role of Endovascular
Therapies in the Management of Diverse
Thoracic Aortic Pathology”
Robert Y. Rhee, MD
T
horacic aortic pathology has always been diffi-
cult to treat surgically because of the morbid-
ity and mortality associated with direct open
repair. Any direct, open, reconstructive procedure
on the thoracic aorta is frequently associated with
long-term disability and significant risks of paralysis.
Therefore, unless the pathology was immediately life
threatening (like a 10 cm aneurysm), conservative
management algorithms based on careful follow-up
and serial imaging studies have been developed and
often followed. The authors in this review revisit
those very same thoracic aortic pathologies (pene-
trating ulcers, complex lesions that may be the
source of distal thromboembolism, coarctations, and
aortoesophageal fistulas) in the modern endovascu-
lar era. With the introduction of an FDA-approved
thoracic stent graft (W. L. Gore, TAG), the indica-
tions for its use have been expanded to include some
of these pathologies.
Clinical conditions such as penetrating ulcers
and even isolated atherosclerotic lesions (causing
distal thromboembolism) are in fact ideal for
endovascular treatment. As the authors advocate,
these pathologies are easily treated with modern
endovascular techniques with minimum risks. One
word of caution is in the treatment of the patient
with diffuse thromboembolism secondary to a
“shaggy” aorta. In general, these patients do poorly
with both direct and endovascular treatments. It is
the widespread nature of the disease pattern that
From the Division of Vascular Surgery, University of Pittsburgh
Medical Center, Pittsburgh, Pennsylvania
Address correspondence to: Robert Y. Rhee, MD, Associate
Professor of Surgery, Clinical Director, Division of Vascular
Surgery, University of Pittsburgh Medical Center, 5200 Centre Ave
(Suite 307), Pittsburgh, PA 15232; e-mail: rheery@upmc.edu.
144
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Perspectives in
Endovascular Therapy
Volume 19 Number 2
June 2007 144-145
© 2007 Sage Publications
10.1177/1531003507305547
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often disallows directed treatment. It is often not
enough to treat (cover with an endograft) the most
severely diseased segment of the aorta, because it
has not been clearly determined that the most sig-
nificant areas (as determined by an imaging study)
are in fact the source of the embolization. As such,
most of these patients should be treated conserva-
tively. In addition, the endovascular manipulation
inside a “shaggy” aorta may propagate or even
worsen the patient’s symptoms.
The endovascular treatment for aortic coarcta-
tions remains very controversial. Angioplasty with
subsequent balloon expandable stent placement has
had less than optimal results as indicated by the
authors. New generations of stentgrafts with greater
radial force may allow safer treatment. Currently,
direct surgical repair with replacement of the dis-
eased segment with a graft is still the treatment of
choice. The final pathology addressed by the authors
is the aortoesophageal fistula. We have treated sev-
eral patients with this pathology with endovascular
techniques, but only as a temporizing measure. By
definition, the endograft is infected once it is in con-
tact with the contents of the bacteria-rich esophagus.
Therefore, after the bleeding is controlled and the
patient is stabilized, the region in question should be
explored and infected aortic tissue debrided followed
by a temporary esophageal diversion procedure. The
endograft may or may not need to be removed after
the diversion as long as the infection is well con-
trolled. After all, even with direct, open repair, in situ
reconstructions have done reasonably well.
In conclusion, endovascular repair of these
diverse aortic pathologies is clearly feasible if not
preferential. However, these techniques should be
reserved for selected patients with favorable
anatomic situations.

Last Word
It is not our intention to promote endovascular
treatment of thoracic aortic pathologies for unap-
proved indications. The physician who is confronted
with these challenging patients must consider all
possible therapeutic options. Considerations must
encompass the potential risks and benefits for each
intervention as well as its durability. Whereas suc-
cessful results have been reported at many centers
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Commentary / Rhee 145
Mark A. Farber, MD
of excellence, patient selection, detailed preproce-
dural planning and clinical experience are critical in
obtaining optimal results. Significant problems can
occur when using these therapies outside controlled
settings and may result in adverse outcomes.
Further device development and midterm data need
to be accrued before endovascular techniques can
be definitively recommended for these pathologies.