Complications of TEVAR

  • Rana O. Afifi
  • Ali Azizzadeh
  • Anthony L. EstreraEmail author


In this chapter, we will be reviewing complications after TEVAR, including mortality, neurological complications (stroke, spinal cord ischemia), complications related to coverage of subclavian artery, device malfunctioning, endoleak, migration, retrograde dissection, and access complications.


TEVAR Endoleak Malperfusion Spinal cord ischemia Retrograde dissection Malfunction Graft infection 


  1. 1.
    Adams JD, Garcia LM, Kern JA. Endovascular repair of the thoracic aorta. Surg Clin North Am. 2009;89:895–912.PubMedCrossRefGoogle Scholar
  2. 2.
    DeBakey ME, McCollum CH, Graham JM. Surgical treatment of aneurysms of the descending thoracic aorta: long-term results in 500 patients. J Cardiovasc Surg. 1978;19:571–6.Google Scholar
  3. 3.
    Coselli JS, LeMaire SA, Conklin LD, Adams GJ. Left heart bypass during descending thoracic aortic aneurysm repair does not reduce the incidence of paraplegia. Ann Thorac Surg. 2004;77:1298–303.PubMedCrossRefGoogle Scholar
  4. 4.
    Estrera AL, Miller CC, Chen EP, et al. Descending thoracic aortic aneurysm repair: 12-year experience using distal aortic perfusion and cerebrospinal fluid drainage. Ann Thorac Surg. 2005;80:1290–6.PubMedCrossRefGoogle Scholar
  5. 5.
    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;331:1729–34.PubMedCrossRefGoogle Scholar
  6. 6.
    Makaroun MS, Dillavou ED, ST K, et al. Endovascular treatment of thoracic aortic aneurysms: results of the phase II multicenter trial of the GORE TAG thoracic endoprosthesis. J Vasc Surg. 2005;41:1–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Makaroun MS, Dillavou ED, Wheatley GH, Cambria RP. Five-year results of endovascular treatment with the Gore TAG device compared with open repair of thoracic aortic aneurysms. J Vasc Surg. 2008;47:912–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Gopaldas RR, Huh J, Dao TK, et al. Superior nationwide outcomes of endovascular versus open repair for isolated descending thoracic aortic aneurysm in 11,669 patients. J Thorac Cardiovasc Surg. 2010;140:1001–10.PubMedCrossRefGoogle Scholar
  9. 9.
    Leurs LJ, Bell R, Degrieck Y, Thomas S, Hobo R, Lundbom J. Endovascular treatment of thoracic aortic diseases: combined experience from the EUROSTAR and United Kingdom Thoracic Endograft registries. J Vasc Surg. 2004;40:670–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Cheng D, Martin J, Shennib H, et al. Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease a systematic review and meta-analysis of comparative studies. J Am Coll Cardiol. 2010;55:986–1001.PubMedCrossRefGoogle Scholar
  11. 11.
    Hughes K, Guerrier J, Obirieze A, et al. Open versus endovascular repair of thoracic aortic aneurysms: a nationwide inpatient sample study. Vasc Endovasc Surg. 2014;48:383–7.CrossRefGoogle Scholar
  12. 12.
    Arnaoutakis DJ, Arnaoutakis GJ, Abularrage CJ, et al. Cohort-comparison of thoracic endovascular aortic repair with open thoracic aortic repair using modern end-organ preservation strategies. Ann Vasc Surg. 2015;29:882–90.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Desai ND, Burtch K, Moser W, et al. Long-term comparison of thoracic endovascular aortic repair (TEVAR) to open surgery for the treatment of thoracic aortic aneurysms. J Thorac Cardiovasc Surg. 2012;144:604–9.PubMedCrossRefGoogle Scholar
  14. 14.
    von Allmen RS, Anjum A, Powell JT. Outcomes after endovascular or open repair for degenerative descending thoracic aortic aneurysm using linked hospital data. Br J Surg. 2014;101:1244–51.CrossRefGoogle Scholar
  15. 15.
    Bicknell C, Powell JT. Aortic disease: thoracic endovascular aortic repair. Heart. 2015;101:586–91.PubMedCrossRefGoogle Scholar
  16. 16.
    Nienaber CA, Rousseau H, Eggebrecht H, et al. Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial. Circulation. 2009;120:2519–28.PubMedCrossRefGoogle Scholar
  17. 17.
    Scali ST, Chang CK, Feezor RJ, et al. Preoperative prediction of mortality within 1 year after elective thoracic endovascular aortic aneurysm repair. J Vasc Surg. 2012;56:1266–72.PubMedPubMedCentralCrossRefGoogle Scholar
  18. 18.
    Shah AA, Barfield ME, Andersen ND, et al. Results of thoracic endovascular aortic repair 6 years after United States Food and Drug Administration approval. Ann Thorac Surg. 2012;94:1394–9.PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Zahn R, Erbel R, Nienaber CA, et al. Endovascular aortic repair of thoracic aortic disease: early and 1-year results from a German multicenter registry. J Endovasc Ther. 2013;20:265–72.PubMedCrossRefGoogle Scholar
  20. 20.
    Patterson B, Holt P, Nienaber C, Cambria R, Fairman R, Thompson M. Aortic pathology determines midterm outcome after endovascular repair of the thoracic aorta: report from the Medtronic Thoracic Endovascular Registry (MOTHER) database. Circulation. 2013;127:24–32.PubMedCrossRefGoogle Scholar
  21. 21.
    Goodney PP, Travis L, Lucas FL, et al. Survival after open versus endovascular thoracic aortic aneurysm repair in an observational study of the Medicare population. Circulation. 2011;124:2661–9.PubMedPubMedCentralCrossRefGoogle Scholar
  22. 22.
    Scali ST, Feezor RJ, Chang CK, et al. Efficacy of thoracic endovascular stent repair for chronic type B aortic dissection with aneurysmal degeneration. J Vasc Surg. 2013;58:10–7.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    Thrumurthy SG, Karthikesalingam A, Patterson BO, et al. A systematic review of mid-term outcomes of thoracic endovascular repair (TEVAR) of chronic type B aortic dissection. Eur J Vasc Endovasc Surg. 2011;42:632–47.PubMedCrossRefGoogle Scholar
  24. 24.
    Nienaber CA, Kische S, Rousseau H, et al. Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Interv. 2013;6:407–16.PubMedCrossRefGoogle Scholar
  25. 25.
    Matsumura JS, Lee WA, Mitchell RS, et al. The Society for Vascular Surgery Practice Guidelines: management of the left subclavian artery with thoracic endovascular aortic repair. J Vasc Surg. 2009;50:1155–8.PubMedCrossRefGoogle Scholar
  26. 26.
    Buth J, Harris PL, Hobo R, et al. Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. A study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) registry. J Vasc Surg. 2007;46:1103–10.PubMedCrossRefGoogle Scholar
  27. 27.
    Gutsche JT, Cheung AT, McGarvey ML, et al. Risk factors for perioperative stroke after thoracic endovascular aortic repair. Ann Thorac Surg. 2007;84:1195–200.PubMedCrossRefGoogle Scholar
  28. 28.
    Bismuth J, Garami Z, Anaya-Ayala JE, et al. Transcranial Doppler findings during thoracic endovascular aortic repair. J Vasc Surg. 2011;54:364–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Feezor RJ, Martin TD, Hess PJ, et al. Risk factors for perioperative stroke during thoracic endovascular aortic repairs (TEVAR). J Endovasc Ther. 2007;14:568–73.PubMedCrossRefGoogle Scholar
  30. 30.
    Melissano G, Civilini E, Bertoglio L, et al. Results of endografting of the aortic arch in different landing zones. Eur J Vasc Endovasc Surg. 2007;33:561–6.PubMedCrossRefGoogle Scholar
  31. 31.
    Greenberg RK, Lu Q, Roselli EE, et al. Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques. Circulation. 2008;118:808–17.PubMedCrossRefGoogle Scholar
  32. 32.
    Melissano G, Tshomba Y, Bertoglio L, Rinaldi E, Chiesa R. Analysis of stroke after TEVAR involving the aortic arch. Eur J Vasc Endovasc Surg. 2012;43:269–75.PubMedCrossRefGoogle Scholar
  33. 33.
    Mariscalco G, Piffaretti G, Tozzi M, et al. Predictive factors for cerebrovascular accidents after thoracic endovascular aortic repair. Ann Thorac Surg. 2009;88:1877–81.PubMedCrossRefGoogle Scholar
  34. 34.
    Ullery BW, Wang GJ, Low D, Cheung AT. Neurological complications of thoracic endovascular aortic repair. Semin Cardiothorac Vasc Anesth. 2011;15:123–40.PubMedCrossRefGoogle Scholar
  35. 35.
    Etheredge SN, Yee J, Smith JV, Schonberger S, Goldman MJ. Successful resection of a large aneurysm of the upper abdominal aorta and replacement with homograft. Surgery. 1955;38:1071–81.PubMedGoogle Scholar
  36. 36.
    DeBakey ME, Creech O, Morris GC. Aneurysm of thoracoabdominal aorta involving the celiac, superior mesenteric, and renal arteries; report of four cases treated by resection and homograft replacement. Ann Surg. 1956;144:549–73.PubMedPubMedCentralCrossRefGoogle Scholar
  37. 37.
    Etz CD, Weigang E, Hartert M, et al. Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgerydagger. Eur J Cardiothorac Surg. 2015;47:943–57.PubMedCrossRefGoogle Scholar
  38. 38.
    Safi HJ, Miller CC 3rd, Carr C, Iliopoulos DC, Dorsay DA, Baldwin JC. Importance of intercostal artery reattachment during thoracoabdominal aortic aneurysm repair. J Vasc Surg. 1998;27:58–66.PubMedCrossRefGoogle Scholar
  39. 39.
    Gravereaux EC, Faries PL, Burks JA, et al. Risk of spinal cord ischemia after endograft repair of thoracic aortic aneurysms. J Vasc Surg. 2001;34:997–1003.PubMedCrossRefGoogle Scholar
  40. 40.
    Khoynezhad A, Donayre CE, Bui H, Kopchok GE, Walot I, White RA. Risk factors of neurologic deficit after thoracic aortic endografting. Ann Thorac Surg. 2007;83:S882–9.PubMedCrossRefGoogle Scholar
  41. 41.
    Safi HJ, Hess KR, Randel M, et al. Cerebrospinal fluid drainage and distal aortic perfusion: reducing neurologic complications in repair of thoracoabdominal aortic aneurysm types I and II. J Vasc Surg. 1996;23:223–8.PubMedCrossRefGoogle Scholar
  42. 42.
    Estrera AL, Sheinbaum R, Miller CC, et al. Cerebrospinal fluid drainage during thoracic aortic repair: safety and current management. Ann Thorac Surg. 2009;88:9–15.PubMedCrossRefGoogle Scholar
  43. 43.
    Maldonado TS, Dexter D, Rockman CB, et al. Left subclavian artery coverage during thoracic endovascular aortic aneurysm repair does not mandate revascularization. J Vasc Surg. 2013;57:116–24.PubMedCrossRefGoogle Scholar
  44. 44.
    Wilson JE, Galinanes EL, Hu P, Dombrovskiy VY, Vogel TR. Routine revascularization is unnecessary in the majority of patients requiring zone II coverage during thoracic endovascular aortic repair: a longitudinal outcomes study using United States Medicare population data. Vascular. 2014;22:239–45.PubMedCrossRefGoogle Scholar
  45. 45.
    Patterson BO, Holt PJ, Nienaber C, Fairman RM, Heijmen RH, Thompson MM. Management of the left subclavian artery and neurologic complications after thoracic endovascular aortic repair. J Vasc Surg. 2014;60:1491–7.PubMedCrossRefGoogle Scholar
  46. 46.
    Zamor KC, Eskandari MK, Rodriguez HE, Ho KJ, Morasch MD, Hoel AW. Outcomes of thoracic endovascular aortic repair and subclavian revascularization techniques. J Am Coll Surg. 2015;221:93–100.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Eggebrecht H, Thompson M, Rousseau H, et al. Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: insight from the European registry on endovascular aortic repair complications. Circulation. 2009;120:S276–81.PubMedCrossRefGoogle Scholar
  48. 48.
    Estrera AL, Shah P, Lee TY, Irani AD, Safi HJ. Repair of retrograde type a aortic dissection after thoracic endovascular aortic aneurysm repair using the modified elephant trunk technique. Vascular. 2009;17:116–20.PubMedCrossRefGoogle Scholar
  49. 49.
    Canaud L, Ozdemir BA, Patterson BO, Holt PJ, Loftus IM, Thompson MM. Retrograde aortic dissection after thoracic endovascular aortic repair. Ann Surg. 2014;260:389–95.PubMedCrossRefGoogle Scholar
  50. 50.
    Idrees J, Arafat A, Johnston DR, Svensson LG, Roselli EE. Repair of retrograde ascending dissection after descending stent grafting. J Thorac Cardiovasc Surg. 2014;147:151–4.PubMedCrossRefGoogle Scholar
  51. 51.
    Fattori R, Lovato L, Buttazzi K, Di Bartolomeo R, Gavelli G. Extension of dissection in stent-graft treatment of type B aortic dissection: lessons learned from endovascular experience. J Endovasc Ther. 2005;12:306–11.PubMedCrossRefGoogle Scholar
  52. 52.
    Neuhauser B, Czermak BV, Fish J, et al. Type A dissection following endovascular thoracic aortic stent-graft repair. J Endovasc Ther. 2005;12:74–81.PubMedCrossRefGoogle Scholar
  53. 53.
    Eggebrecht H, Nienaber CA, Neuhauser M, et al. Endovascular stent-graft placement in aortic dissection: a meta-analysis. Eur Heart J. 2006;27:489–98.PubMedCrossRefGoogle Scholar
  54. 54.
    Tshomba Y, Bertoglio L, Marone EM, Logaldo D, Maisano F, Chiesa R. Retrograde type A dissection after endovascular repair of a “zone 0” nondissecting aortic arch aneurysm. Ann Vasc Surg. 2010;24:952.PubMedCrossRefGoogle Scholar
  55. 55.
    Hata M, Sezai A, Niino T, et al. Prognosis for patients with type B acute aortic dissection: risk analysis of early death and requirement for elective surgery. Circ J. 2007;71:1279–82.PubMedCrossRefGoogle Scholar
  56. 56.
    Dong ZH, Fu WG, Wang YQ, et al. Retrograde type A aortic dissection after endovascular stent graft placement for treatment of type B dissection. Circulation. 2009;119:735–41.PubMedCrossRefGoogle Scholar
  57. 57.
    Williams JB, Andersen ND, Bhattacharya SD, et al. Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair. J Vasc Surg. 2012;55:1255–62.PubMedPubMedCentralCrossRefGoogle Scholar
  58. 58.
    Neuhauser B, Greiner A, Jaschke W, Chemelli A, Fraedrich G. Serious complications following endovascular thoracic aortic stent-graft repair for type B dissection. Eur J Cardiothorac Surg. 2008;33:58–63.PubMedCrossRefGoogle Scholar
  59. 59.
    Czerny M, Weigang E, Sodeck G, et al. Targeting landing zone 0 by total arch rerouting and TEVAR: midterm results of a transcontinental registry. Ann Thorac Surg. 2012;94:84–9.PubMedCrossRefGoogle Scholar
  60. 60.
    Dong Xu S, Zhong Li Z, Huang FJ, et al. Treating aortic dissection and penetrating aortic ulcer with stent graft: thirty cases. Ann Thorac Surg. 2005;80:864–8.PubMedCrossRefGoogle Scholar
  61. 61.
    Jacobs TS, Won J, Gravereaux EC, et al. Mechanical failure of prosthetic human implants: a 10-year experience with aortic stent graft devices. J Vasc Surg. 2003;37:16–26.PubMedCrossRefGoogle Scholar
  62. 62.
    Nienaber CA, Kische S, Ince H. Thoracic aortic stent-graft devices: problems, failure modes, and applicability. Sem Vasc Surg. 2007;20:81–9.CrossRefGoogle Scholar
  63. 63.
    Lee WA. Failure modes of thoracic endografts: prevention and management. J Vasc Surg. 2009;49:792–9.PubMedCrossRefGoogle Scholar
  64. 64.
    Scali ST, Beck AW, Butler K, et al. Pathology-specific secondary aortic interventions after thoracic endovascular aortic repair. J Vasc Surg. 2014;59:599–607.PubMedPubMedCentralCrossRefGoogle Scholar
  65. 65.
    Chaikof EL, Blankensteijn JD, Harris PL, et al. Reporting standards for endovascular aortic aneurysm repair. J Vasc Surg. 2002;35:1048–60.PubMedCrossRefGoogle Scholar
  66. 66.
    White GH, Yu W, May J, Chaufour X, Stephen MS. Endoleak as a complication of endoluminal grafting of abdominal aortic aneurysms: classification, incidence, diagnosis, and management. J Endovasc Surg. 1997;4:152–68.PubMedCrossRefGoogle Scholar
  67. 67.
    Veith FJ, Baum RA, Ohki T, et al. Nature and significance of endoleaks and endotension: summary of opinions expressed at an international conference. J Vasc Surg. 2002;35:1029–35.PubMedCrossRefGoogle Scholar
  68. 68.
    Preventza O, Wheatley GH 3rd, Ramaiah VG, et al. Management of endoleaks associated with endovascular treatment of descending thoracic aortic diseases. J Vasc Surg. 2008;48:69–73.PubMedCrossRefGoogle Scholar
  69. 69.
    Matsumura JS, Cambria RP, Dake MD, Moore RD, Svensson LG, Snyder S. International controlled clinical trial of thoracic endovascular aneurysm repair with the Zenith TX2 endovascular graft: 1-year results. J Vasc Surg. 2008;47:247–57.PubMedCrossRefGoogle Scholar
  70. 70.
    Fairman RM, Criado F, Farber M, et al. Pivotal results of the Medtronic vascular talent thoracic stent graft system: the VALOR trial. J Vasc Surg. 2008;48:546–54.PubMedCrossRefGoogle Scholar
  71. 71.
    Foley PJ, Criado FJ, Farber MA, et al. Results with the talent thoracic stent graft in the VALOR trial. J Vasc Surg. 2012;56:1214–21.PubMedCrossRefGoogle Scholar
  72. 72.
    Matsumura JS, Melissano G, Cambria RP, et al. Five-year results of thoracic endovascular aortic repair with the Zenith TX2. J Vasc Surg. 2014;60:1–10.PubMedCrossRefGoogle Scholar
  73. 73.
    Jordan WD Jr, Rovin J, Moainie S, et al. Results of a prospective multicenter trial of CTAG thoracic endograft. J Vasc Surg. 2015;61:589–95.PubMedCrossRefGoogle Scholar
  74. 74.
    Desai ND, Pochettino A, Szeto WY, et al. Thoracic endovascular aortic repair: evolution of therapy, patterns of use, and results in a 10-year experience. J Thorac Cardiovasc Surg. 2011;142:587–94.PubMedCrossRefGoogle Scholar
  75. 75.
    Hansen CJ, Bui H, Donayre CE, et al. Complications of endovascular repair of high-risk and emergent descending thoracic aortic aneurysms and dissections. J Vasc Surg. 2004;40:228–34.PubMedCrossRefGoogle Scholar
  76. 76.
    Brandt M, Hussel K, Walluscheck KP, et al. Stent-graft repair versus open surgery for the descending aorta: a case-control study. J Endovasc Ther. 2004;11:535–8.PubMedCrossRefGoogle Scholar
  77. 77.
    Song TK, Donayre CE, Walot I, et al. Endograft exclusion of acute and chronic descending thoracic aortic dissections. J Vasc Surg. 2006;43:247–58.PubMedCrossRefGoogle Scholar
  78. 78.
    Morales JP, Greenberg RK, Lu Q, et al. Endoleaks following endovascular repair of thoracic aortic aneurysm: etiology and outcomes. J Endovasc Ther. 2008;15:631–8.PubMedCrossRefGoogle Scholar
  79. 79.
    Parmer SS, Carpenter JP, Stavropoulos SW, et al. Endoleaks after endovascular repair of thoracic aortic aneurysms. J Vasc Surg. 2006;44:447–52.PubMedCrossRefGoogle Scholar
  80. 80.
    Kalish J, Eslami M, Gillespie D, et al. Routine use of ultrasound guidance in femoral arterial access for peripheral vascular intervention decreases groin hematoma rates. J Vasc Surg. 2015;61:1231–8.PubMedCrossRefGoogle Scholar
  81. 81.
    Patel R, Juszczak MT, Bratby MJ, et al. Efficacy and safety of augmenting the preclose technique with a collagen-based closure device for percutaneous endovascular aneurysm repair. Cardiovasc Intervent Radiol. 2015;38:821–6.PubMedCrossRefGoogle Scholar
  82. 82.
    Skagius E, Bosnjak M, Bjorck M, Steuer J, Nyman R, Wanhainen A. Percutaneous closure of large femoral artery access with Prostar XL in thoracic endovascular aortic repair. Eur J Vasc Endovasc Surg. 2013;46:558–63.PubMedCrossRefGoogle Scholar
  83. 83.
    Minion DJ, Davenport DL. Access techniques for EVAR: percutaneous techniques and working with small arteries. Sem Vasc Surg. 2012;25:208–16.CrossRefGoogle Scholar
  84. 84.
    Buck DB, Karthaus EG, Soden PA, et al. Percutaneous versus femoral cutdown access for endovascular aneurysm repair. J Vasc Surg. 2015;62:16–21.PubMedPubMedCentralCrossRefGoogle Scholar
  85. 85.
    Heyer KS, Modi P, Morasch MD, et al. Secondary infections of thoracic and abdominal aortic endografts. J Vasc Interv Radiol. 2009;20:173–9.PubMedCrossRefGoogle Scholar
  86. 86.
    Laser A, Baker N, Rectenwald J, Eliason JL, Criado-Pallares E, Upchurch GR Jr. Graft infection after endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2011;54:58–63.PubMedCrossRefGoogle Scholar
  87. 87.
    Chiesa R, Tshomba Y, Kahlberg A, et al. Management of thoracic endograft infection. J Cardiovasc Surg. 2010;51:15–31.Google Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  • Rana O. Afifi
    • 1
  • Ali Azizzadeh
    • 1
  • Anthony L. Estrera
    • 1
    Email author
  1. 1.Department of Cardiothoracic and Vascular SurgeryMcGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)HoustonUSA

Personalised recommendations