Gen Thorac Cardiovasc Surg DOI 10.1007/s11748-016-0658-8
CURRENT TOPICS REVIEW ARTICLE
Open aortic surgery after thoracic endovascular aortic repair Joseph S. Coselli1,2,3 • Konstantinos Spiliotopoulos1,2,3 • Ourania Preventza1,2,3 Kim I. de la Cruz1,2,3 • Hiruni Amarasekara1,2 • Susan Y. Green1,2
•
Received: 7 April 2016 / Accepted: 13 May 2016 Ó The Japanese Association for Thoracic Surgery 2016
Abstract In the last decade, thoracic endovascular aortic aneurysm repair (TEVAR) has emerged as an appealing alternative to the traditional open aortic aneurysm repair. This is largely due to generally improved early outcomes associated with TEVAR, including lower perioperative mortality and morbidity. However, it is relatively common for patients who undergo TEVAR to need a secondary intervention. In select circumstances, these secondary interventions are performed as an open procedure. Although it is difficult to assess the rate of open repairs after TEVAR, the rates in large series of TEVAR cases ([300) have ranged from 0.4 to 7.9 %. Major complications of TEVAR that typically necessitates open distal aortic repair (i.e., repair of the descending thoracic or thoracoabdominal aorta) include endoleak (especially type I), aortic fistula, endograft infection, device collapse or migration, and continued expansion of the aneurysm sac. Conversion to open repair of the distal aorta may be either elective (as for many endoleaks) or emergent (as for rupture, retrograde complicated dissection, malperfusion, and endograft infection). In addition, in select patients (e.g.,
Paper based on a presentation given by Dr. Coselli at the 68th Annual Scientific Meeting of the Japanese Association for Thoracic Surgery, October 19, 2015. & Joseph S. Coselli
[email protected] 1
Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, BCM 390, Houston, TX 77030, USA
2
Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
3
CHI St. Luke’s Health-Baylor St. Luke’s Medical Center, Houston, TX, USA
those with a chronic aortic dissection), unrepaired sections of the aorta may progressively dilate, resulting in the need for multiple distal aortic repairs. Open repairs after TEVAR can be broadly classified as full extraction, partial extraction, or full salvage of the stent-graft. Although full and partial stent-graft extraction imply failure of TEVAR, such failure is generally absent in cases where the stentgraft can be fully salvaged. We review the literature regarding open repair after TEVAR and highlight operative strategies. Keywords Open surgical repair Thoracic endovascular aortic repair Aortic aneurysm Descending thoracic aorta
Introduction Aortic aneurysm repair is undertaken to prevent death from aortic rupture. Since the 1950s, open repair has been used to replace the aorta with a synthetic graft, thereby reducing the risk of rupture. Thoracic endovascular aortic aneurysm repair (TEVAR) was first approved for use in the US in 2005, and within the last decade has emerged as an appealing alternative to the traditional open aortic aneurysm repair, largely because of the comparatively better early outcomes, including lower perioperative mortality and morbidity rates. Thoracic endovascular aortic aneurysm repair has widely been adapted [1–3], and contemporary use of TEVAR has expanded to include treatment of both acute and chronic aortic dissections. Despite the widespread use of TEVAR in Japan [1] and elsewhere, long-term data establishing the durability of these repairs are still lacking. In patients who have undergone TEVAR, the need for a secondary intervention is relatively common, with rates ranging from 10 to 15 % when used for treating
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degenerative aneurysms [4–6], 16 to 24 % when used for chronic type B aortic dissections [4–8], and 21 to 32 % when used for acute type B dissections [5, 6, 9, 10]. In addition, a lack of operator experience likely plays a role in the development of postoperative complications after TEVAR. In select circumstances, secondary interventions after TEVAR are performed as open procedures. Although it is difficult to assess the rate of open repair after TEVAR, the rates in large series of TEVAR cases ([300) have ranged from 0.4 to 7.9 % [4, 6]. Major complications of TEVAR that typically necessitates open distal aortic repair (i.e., repair of the descending thoracic or thoracoabdominal aorta) include endoleak (especially type I), aortic fistula, infection, device collapse or migration, and continued expansion of the aneurysm sac. Conversion to open repair of the distal aorta may be either elective (as for many endoleaks) or emergent (as for aortic rupture, complicated device-related iatrogenic dissection, malperfusion, or graft infection). In addition, in select patients (e.g., those with a chronic aortic dissection), unrepaired sections of the aorta may progressively dilate, necessitating multiple distal aortic repairs. Open repair after TEVAR can be broadly classified as full extraction, partial extraction, or full salvage of the stent-graft. Full and partial stent-graft extraction imply failure of TEVAR, whereas full salvage of the stent-graft generally indicates that failure has not occurred.
guidelines provide little information regarding when to use open repair to treat endoleaks [11, 12]; Japanese guidelines state that most types of endoleaks can be resolved using an endovascular technique, but open repair is suggested for treating aortic enlargement. Type I endoleaks, particularly type Ia endoleaks, appear to be a common indication for open repair after endovascular repair. Of interest, we published our experience with 35 open repair procedures after TEVAR [13]; the most common indication for subsequent open repair was aneurysmal expansion related to a type Ia endoleak (n = 18, 51 %). Nozdrykowski et al. [4] analyzed the reintervention procedures performed in 317 patients who originally underwent TEVAR for multiple indications. They found that 25 of these patients underwent conversion to open repair. Of these 25 procedures, 8 (32 %) were necessitated by a type Ia endoleak. In a study by Roselli et al. [14] of 50 patients who underwent open repair after TEVAR, 19 patients (38 %) underwent conversion to open repair to treat a type I endoleak, and 14 (28 %) of those endoleaks were type Ia. In those cases, conversion to open repair appeared to occur more often when the stent-graft was used for an off-label purpose or when the repair-landing zone was shorter than recommended. Such cases demonstrate that atypical use of TEVAR (i.e., for hybrid repair, patients with complex anatomy, or early use in aortic dissection) may necessitate a more thorough imaging surveillance protocol. Infection
Full or partial extraction of the stent-graft When complications related to a previous TEVAR procedure are serious and further endovascular repair is unsuitable, full or partial extraction of the stent-graft(s) may be necessary (Figs. 1, 2). Often, in such scenarios, an underlying patient-specific factor (such as having a connective tissue disorder) contributed to the need for a subsequent open repair procedure. In addition, certain indications, such as infection, usually warrant complete removal of the stentgraft. Endoleak Endoleaks are a well-known complication of TEVAR and result from continued blood flow into the aneurysmal sac. Endoleaks are categorized into 4 types according to the manner in which blood leaks into or from the repair site: type I—reperfusion at the proximal (Ia) or distal (Ib) landing zone, type II—retrograde reperfusion from branching vessels, type III—reperfusion from a gap between devices, and type IV (which are rare)—reperfusion through porous fabric. Contemporary practice
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Stent-grafts rarely become infected after TEVAR, but when they do, full extraction of the stent-graft is typically necessary, as long as the patient is able to withstand open repair. It is not always possible to confirm preoperatively whether an endograft is infected, so having symptoms that warrant a high degree of suspicion (e.g., unexplained fever or sepsis) is typically sufficient cause to prepare for full endograft extraction. When examining computed tomographic images of an endograft infection, it is sometimes possible to see pockets of air near the endograft or evidence of a fistula (Fig. 3). Stent-graft infections should be evaluated intraoperatively. Signs of a frank infection may include pus or necrotic tissue. It is advisable to use culture techniques to definitively identify the responsible pathogens. During the open conversion repair, the replacement graft is usually soaked in rifampin to prevent the recurrence of infection. Alternatively, a homograft may be rarely used in place of a synthetic replacement graft, because native tissue is typically less prone to infection than synthetic material. Additional concomitant procedures that may be performed to reduce the potential for recurrent infection include, but are not limited to, wrapping the replacement
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Fig. 1 Illustrations depicting full endograft explantation in a 56-yearold man with a chronic residual DeBakey type I aortic dissection. a The patient originally underwent open replacement of the aortic root, ascending aorta, and aortic arch with a stage 1 elephant trunk approach. While awaiting an open stage 2 elephant trunk, endovascular repair of the descending thoracic aorta was performed at an outside center using the elephant trunk graft as a proximal landing zone. b The open repair procedure consisted of complete removal of
the stent-grafts, followed by extent II thoracoabdominal aortic aneurysm repair. The patient had a normal recovery and was discharged on postoperative day 15. The patient later developed a pseudoaneurysm at the elephant trunk anastomosis; this complication was resolved using an endovascular approach. The patient remained well 8 years later Reproduced with permission from LeMaire et al. [13], Fig. 2. Copyright: The Society of Thoracic Surgeons
graft with pedicled omentum [13], using perigraft catheters to postoperatively irrigate the area with antibiotics, and performing aortic extirpation followed by extra-anatomic bypass (which both removes the actively infected aortic segment and puts distance between the residual site of infection and the replacement graft). These repairs often require intravenous infusion of antibiotics over several weeks, and patients may require lifelong oral antibiotic treatment, as well [15]. In our series of 35 patients who underwent open conversion after TEVAR, 8 patients had a stent-graft infection (5 of which had a concomitant fistula) [13]. In our paper, we detailed the complexity of performing a definitive repair in these patients. Despite using a variety of the surgical adjuncts described above to target the infections in these 8 cases, our results were disappointing—there were 2 early deaths, 2 late reoperations, and 2 late deaths. In Roselli et al.’s [14] series of 50 patients who underwent open repair after TEVAR, 6 patients had an endograft infection. For all 6 patients, the repair procedure involved complete endograft extraction, and for 2 of the patients, an extra-anatomic bypass approach was used. Similar to our experience, the patients in this series who had a graft
infection were difficult to treat (especially if a concomitant fistula was present), and further intervention was needed for most of them; only 2 patients remained alive at the time of the report. The authors suggested that diagnosing and treating an endograft infection before systemic sepsis develops may be beneficial. Szeto and colleagues [16] at the University of Pennsylvania reported their experience with reintervention after TEVAR; 10 of the patients they treated had undergone index TEVAR procedures for various forms of infection (mycotic aneurysm, fistula, and infected homograft). These 10 patients had high complication and reintervention rates—2 died from a rupture at 3 months, 3 underwent open conversion (1 of which resulted in early death), and 5 had successful procedures. Based on these findings, the authors moved towards using TEVAR as a bridge to definitive open repair, once the patient has stabilized, as part of a planned 2-stage approach. Fistula It is uncommon for an aortic fistula to develop after TEVAR, but this complication is considered by many
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Fig. 2 Illustrations depicting partial endograft explantation in a 53-year-old man with chronic DeBakey type III aortic dissection. a The patient originally underwent open replacement of the proximal portion of the descending thoracic aorta. Afterwards, the distal aorta progressively dilated; therefore, the patient underwent endovascular repair 3 years later. The distal aorta continued to expand, resulting in severe abdominal pain. b Extent III thoracoabdominal aortic aneurysm (TAAA) repair was performed. Because the
Fig. 3 Computed tomographic image showing gas around the edges of the endograft, indicating device infection, in a patient with an aortoesophageal fistula Reproduced with permission from LeMaire et al. [13], Fig. 3. Copyright: The Society of Thoracic Surgeons
experts to be the most damaging one associated with TEVAR [13, 16–19]. Although aortic fistulas are notoriously difficult to treat, patients with them rarely survive
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proximal portion of the stent-graft was well-adhered to the aortic wall, it was incorporated into the repair (with the full thickness of the aortic wall retained), and only the distal portion was removed. The patient experienced a few postoperative complications and was discharged on postoperative day 6. The patient remains well nearly 10 years after the surgery Reproduced with permission from LeMaire et al. [13], Fig. 1. Copyright: The Society of Thoracic Surgeons
without treatment. The types of fistulas typically associated with TEVAR include aortobronchial, aortopulmonary, aortoesophageal, and combinations thereof. It is thought that fistulas develop after TEVAR because of the radial pressure the endograft exerts on nearby structures, coverage of arteries that provide blood flow to the esophagus (which could cause ischemic necrosis), a perforation, an infection, or erosion due to either an endoleak or infectionrelated pseudoaneurysm. It is difficult to determine the overall incidence of fistula development after TEVAR, however, reports suggest that it ranges between 1.5 and 1.9 % [4, 20, 21]. Data from the European Registry of Endovascular Aortic Repair Complications (EuREC) showed that the incidence rate of developing an aortobronchial or aortopulmonary fistula after TEVAR is 0.6 % [22] and that of developing an aortoesophageal fistula is 1.5 % [23]. Notably, the EuREC data also showed that patients treated with open repair have significantly higher survival rates than those treated with conservative or re-TEVAR strategies. Although open repair is clearly the best approach to definitive fistula repair, there is a lack of consensus regarding the optimal open approach (e.g., in situ, extraanatomic bypass, or use of a homograft). As in the cases of
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endograft infection, replacement grafts used during fistula repair are commonly soaked with an antibiotic solution. Concomitant procedures used to treat a TEVAR-related fistula include esophagectomy, extensive debridement of lung and other tissues, and second-stage definitive esophageal or bronchial repair. Although TEVAR-related fistulas are challenging to definitively repair and are generally associated with high rates of early mortality, our center and several others have successfully treated TEVAR-related fistulas with open repair procedures [4, 13, 17, 18, 24]. Device-specific mechanical failure True failure of an endograft (e.g., device collapse) is thought to be a rare complication of TEVAR, especially with contemporary second-generation devices. In their report regarding 16 open repairs after TEVAR, Miyahara et al. [25] at Kobe University describe a case of endograft collapse in 1 patient who had originally been treated for a ruptured degenerative aneurysm. During emergent repair of the descending thoracic aorta, the device was completely removed. However, because the stent-graft collapse caused catastrophic distal-organ ischemia, the patient died (this was the only death after these 16 open repairs). Canaud et al. [18] also described their experience with open repair after TEVAR. Of the 236 patients that underwent TEVAR, 14 required subsequent open repair. In one case, the open repair was necessary because of thoracic stent-graft collapse. In that case, the initial TEVAR procedure was performed to emergently treat a traumatic transection in a 27-year-old man. Within 30 days of the procedure, the patient developed pseudocoarctation syndrome and the endograft collapsed. The patient survived open device removal and repair without complication. Lazar et al. [26] described the case of a 24-year-old man who originally underwent TEVAR for acute blunt trauma. Although the procedure was initially successful, the endograft infolded 3 months later, and definitive open repair was necessary. Other reports have also described cases; in which open conversion was used to treat endograft collapse after TEVAR for traumatic transection [27, 28]. Factors thought to contribute to stent-graft collapse include having an aorta with a small diameter or tight arch curvature (as is common in younger patients with traumatic transection) and stentgraft oversizing [29, 30]. Device migration may occur if overlapping stent-grafts separate or otherwise fail to affix to the aorta. These problems are usually due to a size disparity between the stent-graft and the specific aortic segment; commonly, undersizing results in failed fixation of the endograft to the aortic wall and oversizing leads to endograft collapse. Reports of device migration after TEVAR resulting in the need for open repair are rare [31, 32], because usually
endograft migration is addressed with endovascular techniques (i.e., snaring or ‘‘jailing’’ the migrated stent-graft at a site distal to the lesion by implanting an overlapping endograft, snare retrieval in the case of embolization, or disposal of the free-floating stent-graft into a noncritical artery, such as the internal iliac artery or the hypogastric artery). Patients with connective tissue disorders The use of TEVAR in patients with connective tissue disorders, such as Marfan syndrome, is controversial. In an analysis of data from the Talent Medtronic Registry, Marfan syndrome was found to be a significant independent predictor of open conversion after TEVAR, with an adjusted hazard ratio of 9.97 [33]. Although expert guidelines on the treatment of thoracic aortic diseases [11, 12] do not support the routine use of TEVAR in patients with connective tissue disorders, there remains interest in such use [34, 35]. The available literature suggests that TEVAR can be unpredictable in patients with a connective tissue disorder and can result in poor outcomes [36–39]. In a previous study, we noted that in one young patient with a connective tissue disorder and chronic aortic dissection, the patient’s aorta expanded extremely rapidly (nearly 4 cm in 3 weeks) after TEVAR [13]. Similarly, Numata et al. [36] described a case in which the distal aorta of a patient with Marfan syndrome expanded rapidly (2.3 cm in 9 months) after hybrid thoracoabdominal aortic aneurysm repair; ultimately, open conversion was necessary because of the risk of rupture and endograft infection, but the patient never truly recovered after these procedures. Although data are scarce, type II endoleaks may occur more frequently in patients with connective tissue disorders, because branching arteries are generally not compromised by the atherosclerotic process [36]. As a caveat, endovascular repair may be useful to treat patients with connective tissue disorders when the endograft can be landed in existing graft material [40]. For example, these techniques could be used for late complications of open repair (i.e., pseudoaneurysms or patch aneurysms) or progression of repair, and they may be potentially lifesaving as emergent bridge procedures, until the patient can be stabilized for later definitive open repair [41–43]. Approach to removal Although the procedure used for open repair of a failed endograft is often similar to that used for standard repair of a descending thoracic or thoracoabdominal aortic aneurysm, the presence of a failed stent-graft can complicate the repair procedure. To account for the presence of the stent-
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graft, we modify our standard incision to maximize exposure (i.e., enter through the fifth intercostal space rather than the sixth or use a thoracoabdominal approach for an abdominal repair). Many times, the proximal landing zone of the stent-graft impinges upon the brachiocephalic vessels branching off the aortic arch. In such cases, it is often difficult to safely clamp the aorta, and it may be necessary to use hypothermic circulatory arrest, which at our center is an atypical approach for this procedure. Although imaging studies are useful when determining whether the aorta can be safely clamped, a final decision cannot be made until a direct intraoperative inspection takes place. Partial explantation of the stent-graft may be a useful strategy in patients without an infection (Fig. 2). This decision should be made after an intraoperative assessment. Partial explanation should be considered when the stentgraft is found to be well-incorporated, when the patient demonstrates hemodynamic instability in the operating room, or when inflammation or scar tissue is found in the area, making it unsafe to separate the endograft from the aortic wall. For example, if the patient has a well-adhered bifurcated abdominal endograft, it may be better to trim the endograft to prepare for a graft-to-endograft-to-residual aortic wall anastomosis and to leave the bifurcated section in place. In addition, if a portion of an endograft cannot be removed from the aortic arch without causing undue tissue trauma, it is preferable to leave it in place. It is not thought that partial explantation leads to migration of the remaining portion of the endograft, device failure, component separation, or rupture during follow-up.
Full salvage of the stent-graft Under select circumstances, it is possible to fully salvage an endograft from a previous TEVAR (Fig. 4). In such repairs, the stent-graft must be well-adhered to the aortic wall, and the aneurysm should be stable (i.e., free of endoleaks and not expanding) and free of infection. In many ways, this type of repair is not due to failure of the previous TEVAR procedure, but rather due to ‘‘de novo’’ progression of aortic disease into an adjacent aortic section. Commonly, such situations include the progression of aortic disease into aortic segments with branching arteries, which generally limits further endovascular repair [e.g., thoracoabdominal aortic aneurysm (TAAA) or aortic arch repair]. In certain circumstances, it is possible that having previously undergone an endovascular repair may limit the scope of any additional open repair procedures and may reduce operative risk. Although there are only a few published reports describing full salvage of an endograft from a previous TEVAR, we have performed more than a dozen such repairs, and a few recent publications also describe such procedures.
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Full-salvage repairs may be described in the literature as staged hybrid extensive thoracoabdominal aortic repairs [14, 44–46]. This terminology is typically used to describe endovascular repair of the descending thoracic aorta (stage 1) followed by open repair of the thoracoabdominal aorta (stage 2). For example, this term could be used for TEVAR of the majority of a descending thoracic aneurysm (DTA) and subsequent open extent III TAAA repair. In total, the aortic sections repaired during these 2 procedures are equivalent to those repaired during an extent II TAAA repair, which typically replaces the aorta from the left subclavian artery to the infrarenal abdominal aortic bifurcation. The overriding premise for performing thoracoabdominal aortic repairs in stages is that the collateral circulation [47] of the spinal cord may increase during the interval between repairs and reduce the risk of developing postoperative paraplegia. Jain et al. [45] described their experience with a limited number (n = 19) of staged hybrid repair cases. In these cases, TEVAR was used to treat a DTA in patients with acute dissection. These repairs usually covered the aorta from immediately distal to the left subclavian artery to just above the celiac axis. Over time, the thoracoabdominal aorta became sufficiently dilated to warrant further repair. Then, an open extent III or IV TAAA repair was performed. Although the interval between stages was a median of 18 weeks, this interval can be highly variable, ranging from 13 days to 5.7 years. Overall, the results after the second stage were quite good—there were no deaths and only 1 case of permanent paraplegia. One caveat of these findings is that the patients in this cohort were atypically young (mid-50s), as compared with patients who typically undergo TAAA repair (mid-60s). Similarly, Vivacqua and colleagues [44] at the Cleveland Clinic have described their experience with a staged hybrid approach of TEVAR followed by open extent III TAAA repair, in which the endograft is fully salvaged (n = 22). Most of these repairs were performed to treat progression of aortic disease after TEVAR (n = 13) in patients with chronic dissection (n = 16). In this method of reconstruction, the preserved stent-graft serves as a new intimal layer. Simultaneous clamping of the aorta and the stent-graft within it controls the descending aorta, and the aorta is opened distal to the stent-graft. To perform the proximal anastomosis of the extent III repair, the surgeon transects the aorta along with a small portion of the existing stent-graft and, in patients with a chronic dissection, removes the dissecting septum near the stent-graft to permit expansion; then, the full thickness of the aorta, stent-graft, and graft is reinforced with a strip of felt or bovine pericardial tissue. Upon completion of the distal anastomosis, the remaining aortic wall and bovine pericardium are sutured around the graft. Of the 22 procedures reported in this paper, 2 resulted in early death, 1 resulted in paraplegia, and 1 resulted in renal failure.
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Fig. 4 Illustration depicting full salvage of an endograft in a 72-yearold man. a The patient originally underwent endovascular repair of a descending thoracic aortic aneurysm. Although the endograft remained free of endoleaks, the aneurysmal disease progressed to a nearby section of the aorta over a 3.5-year period. b Subsequent open extent IV thoracoabdominal aortic aneurysm (TAAA) repair incorporated the viable endovascular repair. According to our standard
protocol, cerebrospinal fluid drainage is reserved for extent I and II TAAA repairs and, thus, was not used. The patient experienced a brief period of delayed-onset paraparesis and was discharged to a rehabilitation center on postoperative day 22. The patient remains well 4 years after the procedure Printed with the permission of Baylor College of Medicine
An unusual method of full stent-graft salvage after TEVAR has been published as a case report by Mihaly et al. [48]. After the patient developed a type Ib endoleak with distal aortic expansion after undergoing TEVAR for a complicated chronic Stanford type B aortic dissection, a strip of graft material was used to encircle and obliterate the distal secondary intimal fenestration (which was causing the type Ib endoleak and expansion); in addition, the strip was used to compress the false lumen against the true lumen containing the stent-graft. After this, the surgeons subsequently opened the aneurysmal sac, evacuated the giant intramural hematoma, and performed aneurysmorrhaphy to cover the stent-graft with aortic tissue. Notably, they were able to entirely avoid using aortic cross-clamping and circulatory support devices. The patient was still well 5 months after the procedure.
standard open repair is infallible. Complications of TEVAR may be sufficiently severe to warrant open conversion. In the most complex of these cases (i.e., those involving infection or a fistula), open conversion may not be definitive, and more than one reintervention may be necessary. The true incidence of open conversion after TEVAR is difficult to assess, but the need for such repair appears to be greater when TEVAR is used for the nontraditional applications (i.e., beyond aneurysmal repair of limited sections of the descending thoracic aorta). In addition, operator experience and procedure volume may play a role in the intervention rate.
Conclusion The importance of instating surveillance imaging protocols after TEVAR cannot be overstated. Although such protocols should be tailored to the individual patient (e.g., differentiating between young and old patients to adjust for the cumulative effects of radiation), neither TEVAR nor
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