Thoracic Endovascular Aneurysm Repair (TEVAR)

In patients considered at low or intermediate risk for a thoracic aortic aneurysm (TAA) based on their history and physical examination findings, we suggest chest X-ray as the first radiographic test, as it may identify an alternative diagnosis for symptoms and may obviate the need for additional aortic imaging. ( 2 – Weak , C)

In patients considered at high risk for symptomatic TAA or acute aortic syndrome, we recommend urgent imaging, usually computed tomography angiography (CTA) because of its speed and ease of use for preoperative planning. Magnetic resonance angiography (MRA) and transesophageal echocardiography (TEE) are also adequate for screening to identify thoracic aortic disease, but have limited applicability in certain scenarios (discussed further below). ( 1 – Strong , B)

For elective TEVAR cases, we suggest assessment of left ventricular function by transthoracic echocardiography in a patient with dyspnea of unknown origin or in a patient with known congestive heart failure with worsening dyspnea. ( 2 – Weak , C)

If TEVAR is being considered, we recommend fine-cut (≤0.25 mm) CTA of the entire aorta, as well as the iliac and femoral arteries. CTA of the head and neck is also needed to determine the anatomy of the vertebral arteries. ( 1 – Strong , A)

We recommend routine use of three-dimensional centerline reconstruction software for accurate case planning and execution in TEVAR. ( 1 – Strong , B)

We suggest contrast-enhanced MRA for preoperative planning for patients with severe allergy to iodinated contrast material. ( 2 – Weak , C)

We recommend intravascular ultrasound (IVUS) use in TEVAR for TAA to assess landing zones when cross-sectional imaging is of poor quality, a more detailed evaluation of landing zones or branch vessel origins is needed, or a decrease in contrast material use is desired. ( 1 – Strong , B)