European Professional Societies Outline Current TEVAR Practices

Several prominent European organizations have issued a position statement on thoracic endovascular aortic repair (TEVAR), signaling growing interest in the procedure. The report, published online May 4, 2012, ahead of print in the European Heart Journal, details noninvasive treatments for thoracic aortic aneurysm, dissection of the descending aorta, and thoracic aortic injury.

Representing the views of the European Association for Cardio-Thoracic Surgery, the European Society of Cardiology, and the European Association of Percutaneous Cardiovascular Interventions, Martin Czerny, MD, of University Hospital Berne (Bern, Switzerland), and colleagues describe TEVAR as “an emerging treatment modality, which has been rapidly embraced by clinicians treating thoracic aortic disease.” The current report, they say, is meant to enlist multidisciplinary input on the indications and applicability of TEVAR as well as its limitations and complications.

Capturing an Evolving Field

In a telephone interview with TCTMD, Barry T. Katzen, MD, of Baptist Cardiac and Vascular Institute (Miami, FL), said that while the report holds few surprises, its interest lies in its cross-specialty origins and in serving as a snapshot of TEVAR’s development.

Philip P. Goodney, MD, MS, of Dartmouth-Hitchcock Medical Center (Lebanon, NH), similarly told TCTMD in an e-mail communication that the report’s recommendations, “while pertinent, are broad and generic. In other words, there are very few procedure- or device-specific guidelines or mandates.”

Yet the document still provides insight in that it “underscores the fact that in Europe as well as the United States, we are still learning how to best select patients for TEVAR,” he said, adding that further work is required before clinicians can knowledgably choose the best-suited patients, devices, and techniques to optimize outcomes.

Aortic Centers Best Setting for TEVAR

In particular, Dr. Czerny and colleagues emphasize that patient selection should be done via multidisciplinary cooperation at a center focusing on aortic treatment.

“[The ‘aortic center’] concept offers the widest available opinion, an appropriate range of technical options, and adequate infrastructure for endovascular therapy of thoracic aortic disease,” they write. “The involvement of different specialties allows combining the best experience and expertise in medical, interventional, and surgical therapy for tailoring an optimal treatment strategy for the individual patient.”

Dr. Goodney agreed that aortic centers have become “very popular” in the United States and Europe.

But true collaboration is crucial, he advised. “It is vital that aortic experts are able to work together effectively, and this model has become commonplace in many referral centers,” Dr. Goodney said. “While ‘turf’ issues may still remain in some environments, this model makes it easier for patients and referring physicians to direct patients toward collaborative care.”

While the specific care structure—whether ‘aortic centers’ per se, or aneurysm centers, for example—varies, Dr. Katzen commented, “What is happening is that care of complex aortic disease is being directed more and more to tertiary centers that have the ability to treat these very complicated problems. These are among the most complex problems you can have in the cardiovascular system, so developing centers that build resources around treating the aorta is a good idea.”

Acute dissections are the most challenging to treat, he said, noting that the report refers to TEVAR as the “treatment modality of choice.”

“That’s a pretty strong statement, and I agree with it. I think most [would],” Dr. Katzen confirmed. “But treating dissections is much different than treating ordinary aneurysms, and that’s where the centers really come into play.” The ability to perform both surgical and endovascular treatments for dissection is important, he added, as hybrid procedures are becoming more common. “You need to bring a lot of different skills to the table for these extremely complicated problems,” Dr. Katzen said.

Parallels Between United States and Europe

Dr. Goodney related that the report matches up “very closely” with current US practices. “We’re learning about the procedure, and in whom to use it, with many of the same challenges as in Europe,” he said.

When it comes to TEVAR, Dr. Goodney noted 3 key points for practice:

• Anatomy matters most. The report highlights the importance of anatomic- and device-specific preprocedure planning to avoid complications
• Neurologic complications have not gone away. Stroke and spinal cord complications are still common, and strategies to limit these are still evolving
• Choose your patients well. It is important to choose patients in whom rupture risk outweighs procedural risk, in the context of life expectancy

Dr. Katzen also focused on TEVAR-induced neurologic injury, which the report addresses briefly. He called for more details about when spinal cord drainage should be used prophylactically and in whom. Dr. Czerny and colleagues write: “In high-risk patients, preventive cerebrospinal fluid drainage, which has proven efficacy in spinal cord protection during open thoraco-abdominal aneurysm surgery, is strongly recommended.”

But overall, the position statement basically serves as a summary of “what the current state of the art is,” Dr. Katzen said, and “compatible with what I think is the general standard of care here in the United States.”

 

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Source:
Grabenwöger M, Alfonso F, Bachet J, et al. Thoracic endovascular aortic repair (TEVAR) for the treatment of aortic diseases: A position statement from the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2012;Epub ahead of print.

 

 

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