In the ongoing transition from open repair to EVAR with thoracoabdominal aneurysms

(TAAAs): what situations and lesions still are best treated by open surgery

Michael Jacobs, Maastricht, the Netherlands and Aachen, Germany

2003: When is TEVAR contra indicated ?

• Thoraco abdominal aortic aneurysms (TAAA)

• Post dissection descending aneurysms

• Post dissection TAAA

• Aorto bronchial fistula

• Aorta esophageal fistula

• Connective tissue disease related aneurysms

• Young age

2013: When is TEVAR/FEVAR contra indicated ?

• Thoraco abdominal aortic aneurysms (TAAA)

• Post dissection descending aneurysms

• Post dissection TAAA

• Aorto bronchial fistula

• Aorta esophageal fistula

• Connective tissue disease related aneurysms ?

• Young age ?

IMAGINE THIS OCCURS AT THE PROXIMAL SEALING ZONE …

Open TAAA repair: a huge surgical trauma

„Acceptable“ clinical outcomeof TAAA surgery

• Correct indication and well selected patient

• Extensive experienced team, high volume

• Infrastructure: ECC, neuromonitoring, ICU

• New strategy: sequential surgical procedures

Annual TAA(A) activities

Thoracic 50 90% endo10% open

Thoraco-abdominal 90 50% endo50% open

Even with extensive experience and high volume …

• Mortality 10%

• Unexpected morbidity

• Delayed, unexpected morbidity

• Very demanding surgery

• However, if successful, patient‘s future is good

Decision making

• Open TAAA: young patients, CTD, failed endo

• Endo TAAA: all other patients

• No treatment at all: when the risk of endo or open surgery is higher than the risk of rupture (age, renal failure, cardio-pulmonary, .. )

• Open versus endo versus no intervention:

„eye-test“

„EYE-TEST is an accurate diagnostictool with high predictive value for

surgical outcome“