Endovascular management of thoraco-abdominal aneurysms.

The recent advances in stent technology have provided a choice of techniques in the treatment of thoracoabdominal aortic aneurysms. These techniques should reduce the physiological insult associated with aneurysm repair. Because numbers are small and these techniques are still being perfected, there is as yet limited evidence for a significantly improved survival or reduced paraplegia rates. This evidence is particularly limited as early reported series were based upon patients deemed unfit for open repair. The choice of technique is influenced by a number of factors including aneurysm anatomy and physiological reserve of the patient. It must be remembered that a large proportion of these patients are elderly with significant co-morbidities. Thoracoabdominal aneurysms often affect an extensive section of the aorta and this region provides a major proportion of spinal perfusion. Treatment of these patients--by any modality--will always carry significant risks and this explains the persistently high morbidity and mortality figures. Case selection and balancing the risks of treatment with those of the disease itself will remain crucial in providing best management to our patients. With future device improvements a greater proportion of patients may be suitable for endovascular aneurysm repair. The single biggest advance needed to facilitate this is the development of a system allowing 'off the shelf' stenting of urgent cases, but in-situ fenestration will be required to facilitate this and such a technique remains experimental at present.