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ortic aneurysms remain a challenging problem for patients and physicians. There have been major advances
in the treatment of large-vessel aneurysms during the past 10
years. The surgical armamentarium used to treat these aneurysms now includes an endovascular approach that allows the
insertion of a graft to exclude the aneurysm sac from blood
flow. The endovascular repair of abdominal and thoracic
aortic aneurysms has become a viable alternative to open
repair and is often the approach of choice for high-risk
patients. In this review, we examine the endovascular treatment of abdominal and thoracic aortic aneurysms.
From the Baptist Cardiac and Vascular Institute (B.T.K., A.A.M.), Miami, Fla; University of Virginia Health System (M.D.D.), Charlotteville ; and
Stanford University School of Medicine (D.S.W.), Stanford, Calif.
Correspondence to Barry T. Katzen, MD, Founder and Medical Director, 8900 N Kendall Dr, Miami, FL 33176-2197. E-mail barryk@baptisthealth.net
(Circulation. 2005;112:1663-1675.)
2005 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org
DOI: 10.1161/CIRCULATIONAHA.105.541284
1663
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by guest on January 28, 2015
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Circulation
Katzen et al
TABLE 1.
1665
ists can deal with some of these challenges, but morphological features of the aneurysm and access vessels may preclude
EVAR.
Currently, we use EVAR primarily to treat patients at high
surgical risk. We are confident that EVAR protects patients
from aneurysm rupture, but we cannot yet extend the offer of
EVAR to young, healthy patients, because we do not have
data on long-term durability to support this practice.
Devices
Endograft Devices
FDA Approval
Main Body
Diameter, mm
Fixation
Profile
September 1999
2026
Infrarenal
21F
AneuRx (Medtronic)/worldwide
September 1999
2228
Infrarenal
21F
Excluder (Gore)/worldwide
November 1999
2331
Infrarenal
18F
Device (Company)/Market
Fortron (Cordis)/Europe
No
2634
Suprarenal
NA
No
2129
Infrarenal
21F
Powerlink (Endologix)/Europe
No
2534
Infrarenal; suprarenal
21F
No
2226
Infrarenal
21F
No
2434
Suprarenal
22F/24F
No
1626
Infrarenal
16F
May 2003
2232
Suprarenal
18F/20F
Zenith (Cook)/worldwide
1666
TABLE 3.
Circulation
EVAR Outcomes
EVAR Cases, n
Conversion Rate
Endoleak
Delayed Rupture
Mortality
Ancure/EGS (Guidant),
compared with open surgery12
Device (Company)
2.80%
25.60% at 60 months
AneuRx (Medtronic)13
13% at 1 month
2% 30-Day rate
20% at 2 years
1% 30-Day rate
Fortron (Cordis)
study results not yet available
NA
NA
NA
NA
NA
Lifepath (Edwards)30
227 Patients; 11
months (mean)
follow-up
2.20%
5.90% at 6 months
1.3% Perioperative
Powerlink (Endologix)31
118 Patients; 16
months (mean)
follow-up
3.30%
5.90% at 30 days
0.8% Perioperative
23 Patients; 3-year
(median) follow-up
30%
65%
NA
NA
2.50%
10% at 12 months
NA
NA
NA
NA
NA
200 Patients
1.50%
7.40% at 12 months
0.5% 12 Months
Stentor/Vanguard (Boston
Scientific)32
Outcomes
Table 3 describes the published literature from large devicespecific series.9,10,1214,30 32 Some of the series compare the
EVAR data with that obtained from open surgical repair.
Recently, a prospective, randomized trial of EVAR and open
repair demonstrated a two thirds reduction in early mortality
with EVAR.33 All studies have shown excellent rupture-free
survival and significant reduction in blood loss, cardiovascular events, and intensive care unit stay. High-volume institutions with experience using multiple types of endografts are
able to optimize the matching of the device to the characteristics of the aneurysm.
Complications
Most of the complications associated with EVAR are minor
and can be watched carefully or treated easily with additional
interventional procedures. Some complications occur during
or soon after the procedure, whereas others are only noticed
during graft surveillance (Table 4).34 A study by Ohki et al35
analyzed complication and death rates within 30 days of
EVAR and found the major complication and death rates
Katzen et al
TABLE 4.
EVAR Complications
Deployment related
Failed deployment
Bleeding
Hematoma
Lymphocele
Infection
Embolization
Perforation
Arterial rupture
Dissection
Device related
Structural failure
Implant related
Endoleaks
Limb occlusion/stent-graft kink
Sac enlargement/proximal neck dilatation
Stent migration
AAA rupture
Infection
Buttock/leg claudication
Systemic
Cardiac
Pulmonary
Renal insufficiency
Cerebrovascular
Deep vein thrombosis
Pulmonary embolus
Coagulopathy
Bowel ischemia
Spinal cord ischemia
Erectile dysfunction
Classification of Endoleaks
1667
Surveillance
Endograft surveillance is important to document normal and
abnormal morphological changes in the repair and the involved vessels. This process is vital for the detection of
endoleaks, increased aneurysm diameter, and possible device
migration.43 The study by Corriere et al43 showed that 24% of
the patients had an endoleak detected during surveillance that
averaged 19 months. In that study, 3 endoleaks were detected
2 years after repair, with 1 at 7 years. Other findings,
including perigraft air, accompanied by leukocytosis and
fever, can be detected after repair and have been shown to be
nonspecific and not indicative of graft infection.44
The recommended surveillance routine is for a CT scan at
1, 6, and 12 months and annually thereafter. If an endoleak is
detected, the frequency of the scans increases to every 6
months until resolution of the endoleak is detected. Investigators have compared duplex ultrasound with CT scan for
surveillance and found that CT scan is superior for endoleak
detection.45 MRI can also be used for graft surveillance,
especially in older patients with decreased renal function.46 A
recent development for endograft surveillance is the monitoring of sac pressure within treated aneurysms through an
implanted sensor device.47,48 Trials with this implanted sensor
are currently being conducted.
The use of EVAR technology has led to a greater understanding of the basic science of aneurysmal disease. For
example, Curci and Thompson6 have been studying the
relationship between the secretion of matrix metalloproteinases (MMPs) and AAAs. They have measured increased
levels in the aneurysmal rather than the normal arterial wall.
1668
Circulation
TABLE 6.
Future Directions
EVAR has clear benefits, especially in high-risk patients.
After long-term durability studies have been completed, we
will have a better idea of the role of EVAR in young, healthy
patients. The future of EVAR is exciting, with many new
developments on the horizon. The next generation of endografts will have smaller delivery systems that will permit
the application of this technology to a broader group of
patients. There are endograft designs in development that will
allow us to better treat aneurysms with short proximal necks
and tortuous iliac arteries. The results of ongoing clinical
trials will help elucidate the role of branched endografts that
facilitate treatment of suprarenal aneurysms. A new implantable sac pressuremonitoring device is being studied, and the
utility of this device in the surveillance of the endovascular
repair may help decrease the frequency of follow-up CT
scans. The EVAR story is still being written. This technology
is helpful to a segment of the population of patients with
AAAs, and more study will only broaden its application.
Katzen et al
logically more demanding and carries a greater operative risk.
It mandates open thoracotomy, aortic cross-clamping, resection of the aneurysm, and replacement with a prosthetic graft,
and it often requires cardiopulmonary bypass.60 Despite
advances in operative technique, intraoperative monitoring,
and postoperative care, the mortality and morbidity of surgery
remain substantial and less favorable than outcomes for open
AAA repair. Mortality for TAA surgical repair ranges from
5% to 20% in elective cases and to 50% in emergent
situations.58,61 63 Major complications associated with surgical TAA treatment include renal and pulmonary failure,
visceral and cardiac ischemia, stroke, and paraplegia. Paraplegia is a particularly devastating complication nearly unique
to the surgical treatment of thoracic aneurysms, occurring in 5%
to 25% of cases versus 1% for AAAs.56,58,64 67 For these
reasons, a significant population of TAA patients are not
candidates for open repair and have been without a treatment
option until recently.
Endovascular aneurysm repair of the thoracic aorta is
currently focused on the descending portion, defined as being
distal to the left subclavian artery. Approximately half of
TAAs are located in the descending thoracic aorta.51,59
Anatomically, this aortic segment provides a substrate more
amenable for endovascular stent-graft repair given its avoidance of the great vessels proximally and major visceral
branches and aortic bifurcation distally. Despite these anatomic advantages and the ability to draw from early experiences with endovascular AAA repair, the development of
stent grafting in the thoracic aorta has progressed more
slowly than that of its infrarenal counterpart. The thoracic
aorta poses several unique challenges that have impeded
simple adaptation of endovascular devices and techniques
developed for the abdominal aorta.68 First, the hemodynamic
forces of the thoracic aorta are significantly more aggressive
and place greater mechanical demands on thoracic endografts. The potential for device migration, kinking, and late
structural failures are important concerns. Second, greater
flexibility is required of thoracic devices to conform to the
natural curvature of the proximal descending aorta and to
lesions with tortuous morphology. Third, because larger
devices are necessary to accommodate the diameter of the
thoracic aorta, arterial access is more problematic. This is an
important concern given the greater proportion of TAA
patients, relative to AAA patients, who are women, in whom
access vessels tend to be smaller. Fourth, as with conventional open TAA repair, paraplegia remains a potential
complication in the endovascular approach despite the absence of aortic cross-clamping.69,70 Lastly, the extent of
TAAs can often extend beyond the boundaries of the descending thoracic aorta and involve more proximal or distal
TABLE 7.
TAG (Gore)
Talent (Medtronic)
1669
Devices
Early clinical experiences with stent grafting of the thoracic
aorta were based on the use of first-generation, homemade
devices that were rigid and required large delivery systems
(24F to 27F).74,75 Fortunately, several commercial manufacturers of abdominal endografts have created derivatives for
the thoracic aorta with dramatic improvements over homemade devices. To date, none have been approved for use in
the United States, but 3 are undergoing clinical trials for FDA
approval (Figure 4; Table 7): TAG (W.L. Gore and Associates, Inc), Talent (Medtronic, Inc), and TX2 (Cook, Inc).
Although each device has unique features, all 3 employ the
same basic structural design. The endoprostheses are composed of a stent (nitinol or stainless steel) covered with fabric
(polyester or PTFE). The modular design of the TX2 system
renders it less flexible than the TAG but more so than the
Talent. The TAG device uses a delivery system that is
specifically designed to limit distal migration. The design of
Device (Company)
TX2 (Cook)
Stent/Graft Material
Delivery Profile
Nitinol/PTFE
20F to 24F
Unique Properties
Flexible
Nitinol/polyester
22F to 27F
Uncovered proximally
Stainless steel/polyester
20F to 22F
Fixation barbs
1670
TABLE 8.
of TAA
Circulation
common iliac or abdominal aorta. Additionally, severe stenosis and tortuosity of the abdominal and thoracic aorta distal
to the target are contraindications for endovascular repair.
In spite of the use of these criteria, treatment failures can
occur, but the specific contributing factors and frequencies
are currently unknown, particularly over the long-term. Thus,
follow-up surveillance with serial CT scans at 1, 6, and 12
months and annually thereafter is recommended to monitor
changes in aneurysm morphology, identify device failures,
and detect endoleaks.
Clinical Experience
the proximal and distal ends varies, and some of the stents are
uncovered proximally and distally (TX2), whereas others
have an uncovered proximal end (Talent). In addition, the
TX2 stent uses barbs to facilitate fixation proximally and
distally. Ultimately, each device has its advantages and
disadvantages.
Katzen et al
TABLE 9.
1671
Mean
Follow-Up,
mo
30-Day Mortality,
%
Long-Term
Survival, %
Paraplegia,
%
73 (Actuarial 2 year)
10
NA
20
3.1
15.4
14.3
Devices
Technical Success
Homemade
Talent
Dake 199875
103
Ehrlich 199876
10
NA
Cartes-Zumelzu 200077
32
16
Excluder, Talent
90.6%
22
9.4
Grabenwoger 200078
21
NA
Talent, Prograft
100%
9.5
NA
Greenberg 200079
25
15.4
Homemade
NA
NA
12
Temudom 200080
14
5.5
Homemade, Vanguard,
Excluder
78.6%
14.3
NA
7.1
Endoleak,
%
24
12
14.3
Najibi 200281
24
12
Excluder, Talent
94.7%
5.3
89.5 (1 Year)
Heijmen 200282
28
21
96.4%
28.6
Schoder 200383
28
22.7
Excluder
25
Marin 200384
94
15.4
Excluder, Talent
85.1%
NA
NA
NA
24
Lepore 200385
21
12
Excluder, Talent
100%
9.5
76.2 (1 Year)
4.8
19
Sunder-Plassman 200386
45
21
NA
6.7
NA
2.2
22.2
Ouriel 200368
31
Excluder, Talent,
Other commercial
NA
12.9
81.6 (1 Year)
6.5
32.3
Bergeron 200387
33
24
Excluder, Talent
NA
9.1
Czerny 200488
54
38
Excluder, Talent
94.4%
9.3
27.8
Makaroun 200489
142
29.6
TAG
97.9%
1.5
Leurs 200490
249
160
Excluder, Talent,
Zenith, Endofit
87%
80.3 (1 Year)
Complications
With the avoidance of aortic cross-clamping and prolonged
iatrogenic hypotension, endovascular TAA repair was expected to result in lower incidences of paraplegia relative to
conventional treatment. Indeed, this has held true, with
paraplegia rates generally ranging from 0% to 5% in endovascular studies,68,7590 whereas paraplegia occurs in 5% to
25% of open repair cases.56,58,64,65 Although low, these rates
remain significant, especially because it is impossible to
reimplant intercostal arteries in this setting. Some evidence
suggests that the occurrence of paraplegia is associated with
concomitant or prior surgical AAA repair and increased
exclusion length because of the absence of lumbars and
hypogastric collateral circulation.79,91 Adjunctive measures to
further reduce spinal cord ischemic complication rates in
endovascular TAA repair are being investigated.92
Endoleaks are the most prevalent of TAA stent-graft
treatment complications. However, their observed frequency
is substantially less than that reported for AAA endograft
3.5
8.8
4.2
Future Directions
The cumulative worldwide experience with endovascular
repair of thoracic aneurysms has highlighted not only its
potential as an advance in treatment but also its limitations.
Efforts are under way to expand the applicability of endovascular stent-graft technology in the thoracic aorta, challenging
current anatomic constraints and clinical indications. A variety of exciting strategies are being explored and deserve
mention.
Although current anatomic criteria limit thoracic stentgraft exclusion to lesions located at least 15 to 25 mm away
from the origin of the left subclavian artery and celiac trunk,
it is common for descending TAAs to be located within the
proximal or distal neck length necessary for adequate fixa-
1672
Circulation
Conclusions
The emergence of endovascular stent grafting as an alternative therapy to open surgical repair of abdominal and thoracic
aneurysms is an exciting advance. Although it is apparent that
high-operative-risk patients will benefit from this technology,
the exact role of stent grafting remains to be defined as we
continue to accumulate long-term data and experience and as
devices and techniques evolve. Instead of replacing conventional surgical treatment, endovascular repair will likely play
a complementary role and offer a less invasive option in our
treatment armamentarium. It is clear that the limitations of
both approaches are distinct. Although what is considered
high risk for surgery is defined by clinical parameters in terms
of comorbidities and physiological reserve, contraindications
for endovascular stent-graft treatment are defined by anatomical constraints. In this regard, each may fulfill the treatment
gaps left by the other.
Disclosures
Dr Dake has received research grants from Cook and W.L. Gore; has
served on the speakers bureau of Cook; and has consulted for W.L.
Gore. Dr Katzen has consulted for and received educational grants
from Cook, Boston Scientific, W.L. Gore, and Medtronic.
References
1. Ernst CB. Abdominal aortic aneurysm. N Engl J Med. 1993;328:
11671172.
2. Thomas PR, Stewart RD. Abdominal aortic aneurysm. Br J Surg. 1988;
75:733736.
3. Noel AA, Gloviczki P, Cherry KJ Jr, Bower TC, Panneton JM, Mozes
GI, Harmsen WS, Jenkins GD, Hallett JW Jr. Ruptured abdominal aortic
aneurysms: the excessive mortality rate of conventional repair. J Vasc
Surg. 2001;34:41 46.
4. Scott RA, Wilson NM, Ashton HA, Kay DN. Influence of screening on
the incidence of ruptured abdominal aortic aneurysm: 5-year results of a
randomized controlled study. Br J Surg. 1995;82:1066 1070.
5. Wassef M, Baxter BT, Chisholm RL, Dalman RL, Fillinger MF,
Heinecke J, Humphrey JD, Kuivaniemi H, Parks WC, Pearce WH,
Platsoucas CD, Sukhova GK, Thompson RW, Tilson MD, Zarins CK.
Pathogenesis of abdominal aortic aneurysms: a multidisciplinary
research program supported by the National Heart, Lung, and Blood
Institute. J Vasc Surg. 2001;34:730 738.
6. Curci JA, Thompson RW. Adaptive cellular immunity in aortic aneurysms: cause, consequence, or context? J Clin Invest. 2004;114:
168 171.
7. Fillinger MF, Marra SP, Raghavan ML, Kennedy FE. Prediction of
rupture risk in abdominal aortic aneurysm during observation: wall
stress versus diameter. J Vasc Surg. 2003;37:724 732.
8. Fillinger MF, Raghavan ML, Marra SP, Cronenwett JL, Kennedy FE. In
vivo analysis of mechanical wall stress and abdominal aortic aneurysm
rupture risk. J Vasc Surg. 2002;36:589 597.
9. Criado FJ, Fairman RM, Becker GJ. Talent LPS AAA stent graft: results
of a pivotal clinical trial. J Vasc Surg. 2003;37:709 715.
10. Matsumura JS, Brewster DC, Makaroun MS, Naftel DC. A multicenter
controlled clinical trial of open versus endovascular treatment of
abdominal aortic aneurysm. J Vasc Surg. 2003;37:262271.
11. Ouriel K, Clair DG, Greenberg RK, Lyden SP, OHara PJ, Sarac TP,
Srivastava SD, Butler B, Sampram ES. Endovascular repair of
Katzen et al
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
1673
1674
Circulation
51. Bickerstaff LK, Pairolero PC, Hollier LH, Melton LJ, Van Peenen HJ,
Cherry KJ, Joyce JW, Lie JT. Thoracic aortic aneurysms: a
population-based study. Surgery. 1982;92:11031108.
52. Coady MA, Rizzo JA, Goldstein LJ, Elefteriades JA. Natural history,
pathogenesis, and etiology of thoracic aortic aneurysms and dissections.
Cardiol Clin. 1999;17:615 635.
53. Crawford ES, DeNatale RW. Thoracoabdominal aortic aneurysm: observations regarding the natural course of the disease. J Vasc Surg. 1986;
3:578 582.
54. McNamara JJ, Pressler VM. Natural history of arteriosclerotic thoracic
aortic aneurysms. Ann Thorac Surg. 1978;26:468 473.
55. Johansson G, Markstrom U, Swedenborg J. Ruptured thoracic aortic
aneurysms: a study of incidence and mortality rates. J Vasc Surg.
1995;21:985988.
56. DeBakey ME, McCollum CH, Graham JM. Surgical treatment of aneurysms of the descending thoracic aorta: long-term results in 500 patients.
J Cardiovasc Surg (Torino). 1978;19:571576.
57. Hilgenberg AD, Rainer WG, Sadler TR Jr. Aneurysm of the descending
thoracic aorta: replacement with the use of a shunt or bypass. J Thorac
Cardiovasc Surg. 1981;81:818 824.
58. Moreno-Cabral CE, Miller DC, Mitchell RS, Stinson EB, Oyer PE,
Jamieson SW, Shumway NE. Degenerative and atherosclerotic aneurysms of the thoracic aorta: determinants of early and late surgical
outcome. J Thorac Cardiovasc Surg. 1984;88:1020 1032.
59. Pressler V, McNamara JJ. Thoracic aortic aneurysm: natural history and
treatment. J Thorac Cardiovasc Surg. 1980;79:489 498.
60. Fann JI. Descending thoracic and thoracoabdominal aortic aneurysms.
Coron Artery Dis. 2002;13:93102.
61. Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Variables
predictive of outcome in 832 patients undergoing repairs of the
descending thoracic aorta. Chest. 1993;104:1248 1253.
62. Borst HG, Jurmann M, Buhner B, Laas J. Risk of replacement of
descending aorta with a standardized left heart bypass technique.
J Thorac Cardiovasc Surg. 1994;107:126 132.
63. Pressler V, McNamara JJ. Aneurysm of the thoracic aorta: review of 260
cases. J Thorac Cardiovasc Surg. 1985;89:50 54.
64. Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience
with 1509 patients undergoing thoracoabdominal aortic operations. J
Vasc Surg. 1993;17:357368.
65. Livesay JJ, Cooley DA, Ventemiglia RA, Montero CG, Warrian RK,
Brown DM, Duncan JM. Surgical experience in descending thoracic
aneurysmectomy with and without adjuncts to avoid ischemia. Ann
Thorac Surg. 1985;39:37 46.
66. Berg P, Kaufmann D, van Marrewijk CJ, Buth J. Spinal cord ischaemia
after stent-graft treatment for infra-renal abdominal aortic aneurysms:
analysis of the EUROSTAR database. Eur J Vasc Endovasc Surg.
2001;22:342347.
67. Rosenthal D. Spinal cord ischemia after abdominal aortic operation: is it
preventable? J Vasc Surg. 1999;30:391397.
68. Ouriel K, Greenberg RK. Endovascular treatment of thoracic aortic
aneurysms. J Card Surg. 2003;18:455 463.
69. Dake MD. Endovascular stent-graft management of thoracic aortic
diseases. Eur J Radiol. 2001;39:42 49.
70. Gravereaux EC, Faries PL, Burks JA, Latessa V, Spielvogel D, Hollier
LH, Marin ML. Risk of spinal cord ischemia after endograft repair of
thoracic aortic aneurysms. J Vasc Surg. 2001;34:9971003.
71. Burks JA Jr, Faries PL, Gravereaux EC, Hollier LH, Marin ML. Endovascular repair of thoracic aortic aneurysms: stent-graft fixation across
the aortic arch vessels. Ann Vasc Surg. 2002;16:24 28.
72. Gorich J, Asquan Y, Seifarth H, Kramer S, Kapfer X, Orend KH,
Sunder-Plassmann L, Pamler R. Initial experience with intentional
stent-graft coverage of the subclavian artery during endovascular
thoracic aortic repairs. J Endovasc Ther. 2002;9(suppl 2):II39 II43.
73. Tiesenhausen K, Hausegger KA, Oberwalder P, Mahla E, Tomka M,
Allmayer T, Baumann A, Hessinger M. Left subclavian artery management in endovascular repair of thoracic aortic aneurysms and aortic
dissections. J Card Surg. 2003;18:429 435.
74. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP.
Transluminal placement of endovascular stent-grafts for the treatment of
descending thoracic aortic aneurysms. N Engl J Med. 1994;331:
1729 1734.
75. Dake MD, Miller DC, Mitchell RS, Semba CP, Moore KA, Sakai T. The
first generation of endovascular stent-grafts for patients with aneurysms of the descending thoracic aorta. J Thorac Cardiovasc Surg.
1998;116:689 703.
Katzen et al
97.
98.
99.
100.
101.
1675
102. Heinemann MK, Buehner B, Jurmann MJ, Borst HG. Use of the
elephant trunk technique in aortic surgery. Ann Thorac Surg. 1995;
60:2 6.
103. Fann JI, Dake MD, Semba CP, Liddell RP, Pfeffer TA, Miller DC.
Endovascular stent-grafting after arch aneurysm repair using the
elephant trunk. Ann Thorac Surg. 1995;60:11021105.
104. Dake MD, Kato N, Mitchell RS, Semba CP, Razavi MK, Shimono T,
Hirano T, Takeda K, Yada I, Miller DC. Endovascular stent-graft
placement for the treatment of acute aortic dissection. N Engl J Med.
1999;340:1546 1552.
105. Kato N, Dake MD, Miller DC, Semba CP, Mitchell RS, Razavi MK,
Kee ST. Traumatic thoracic aortic aneurysm: treatment with endovascular stent-grafts. Radiology. 1997;205:657 662.
106. Eggebrecht H, Baumgart D, Schmermund A, Herold U, Hunold P, Jakob
H, Erbel R. Penetrating atherosclerotic ulcer of the aorta: treatment by
endovascular stent-graft placement. Curr Opin Cardiol. 2003;18:
431 435.
107. Kato N, Hirano T, Ishida M, Shimono T, Cheng SH, Yada I, Takeda K.
Acute and contained rupture of the descending thoracic aorta: treatment
with endovascular stent grafts. J Vasc Surg. 2003;37:100 105.
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