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Thoracic endovascular aortic repair

By Geraldine M. O’Leary, MSN, RN, FNP-BC

Abstract: Thoracic endovascular aortic repair (TEVAR) has emerged as the surgical treatment of choice for patients with thoracic aortic aneurysm. This article focuses on the indications, contraindications, diagnostic studies, procedure, complications, nursing considerations, and patient discharge instructions for patients undergoing a TEVAR.

Keywords: aorta, aortic dissection, endoleak, fistula, stent graft, thoracic aortic aneurysm (TAA), thoracic endovascular aortic repair (TEVAR)

Thoracic aortic disease affects 3 to 6 per 100,000 people per year, with thoracic aortic aneurysms (TAAs) accounting for approximately 25% of all aneurysms.1,2 According to the CDC, diseases of the aorta and its branches account for 43,000 to 47,000 deaths annually in the US.3 TAAs can be treated with open surgical repair or tho- racic endovascular aortic repair (TEVAR).4 This article focuses on the indications and contraindica- tions of TEVAR, diagnostic stud- ies, the TEVAR procedure and complications, as well as nursing considerations and patient dis- charge instructions.

Anatomy of aneurysms The aorta is the largest artery in the body and supplies oxygen, nutrients, and blood to all the vital organs. One of the most common problems affecting the

aorta is an aneurysm. An aneu- rysm is an outpouching or dilation of a blood vessel that results from vessel wall weakening, which may occur in different areas of the aorta.5,6 A true aneurysm can be identified by its shape and is described as fusiform or saccular. The more common fusiform- shaped aneurysm bulges, or balloons out, on all sides of the blood vessel. A saccular-shaped aneurysm bulges, or balloons out, only on one side.5,6 (See Types of aortic aneurysms.)

Surgical intervention guidelines A TAA is often asymptomatic and found on evaluation for an unrelated problem. The need for intervention is based on the size of the aneurysm.1 The overall goal is to prevent rupture.2 The American Heart Association/ American College of Cardiology

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Thoracic endovascular aortic repair

(AHA/ACC) guidelines recom- mend surgical referral when the aortic root, or the ascending aorta diameter, measures 5.5 cm or more. For aneurysms less than 4.0 cm in arch diameter, 12-month interval screening is recommended. Six-month intervals are recommended for aneurysms 4.0 to 5.4 cm in arch diameter.3

Indications TEVAR was first described by Dake and colleagues in 1994 and was initially used in the treatment of descending aortic aneurysms.7 (See TEVAR.) Today, its use has expanded to include aortic arch aneurysms, penetrat- ing atherosclerotic aortic ulcers, and traumatic aortic injury.8-10

The advantages of TEVAR over traditional open surgical repair include decreased perioperative blood loss, operative time, and morbidity, and shorter ICU and hospital stays.11-15

Contraindications Other than a known allergy to any of the components used in a stent graft, there are no absolute contraindications for TEVAR. Relative contraindications to consider include extremely tortu- ous, calcified or small femoral or iliac arteries; curvature or kinking of the aortic arch seg- ment; infection; and underlying connective tissue disease such as Marfan syndrome or Loeys-Dietz syndrome.10,13 According to the AHA/ACC guidelines, patients with connective tissue disorders and without significant comor- bidities should undergo open repair.1,3 Another relative con- traindication to consider is the patient’s ability to comply with the follow-up surveillance neces- sary after the procedure.12

Diagnostic studies The initial evaluation of a patient with a TAA includes a complete health history and

Types of aortic aneurysms A. Normal artery.

B.True aneurysm. One, two, or all three layers may be involved.

C. Fusiform aneurysm—symmetric, spindle-shaped expansion of entire cir-

cumference of involved vessel.

D. Saccular aneurysm—a bulbous protrusion of one side of the arterial wall.

A B C D

Reprinted with permission from Morton PG, Fontaine DK, eds. Critical Care Nursing: A Holistic

Approach. 11th ed. Philadelphia, PA: Wolters Kluwer; 2018.

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physical assessment by the car- diovascular surgeon and cardi- ologist. ECG, chest X-ray, and lab studies are also obtained.2

Computed tomography angiog- raphy (CTA) is the mainstay of evaluation, with the ability to measure aneurysm dimensions, the diameters and lengths of the abdominal and pelvic arteries, as well as identify extensive throm- bus or calcifications.1,12

TEVAR procedure A hybrid OR, which is outfitted with a full complement of OR equipment plus state-of-the-art imaging technology, is used for the TEVAR procedure in order to provide high-definition radio- graphic imaging and a mobile table. The patient, placed under general anesthesia and controlled ventilation, is positioned with groins, abdomen, and chest exposed.16 A radial artery cath- eter is placed to monitor systemic BP. The femoral artery is then accessed with an angiographic sheath, and a rigid guidewire is advanced to the ascending aorta under fluoroscopy.10,16 If needed, an angled glide catheter can steer the guide wire into the ascending aorta. A pigtail catheter inserted via the femoral artery is used to perform an aortogram. After the aortogram, the proximal neck is evaluated. The length and diam- eter of the proximal and distal neck are measured using the preoperative CTA, an intravas- cular ultrasound, and the aorto- gram.17 The stent graft is chosen based on these measurements.10

Selection of the optimal stent graft size is of critical importance in minimizing the risk of endo- leak formation, migration, ret-

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rograde type A aortic dissection, and rupture.10,18 The stent graft is made of a high-density, multi- filament polyester graft material that has low porosity.19 One stent or multiple overlapping stents can be used for greater coverage depending on aneurysm size.

The patient is heparinized to an activated clotting time (ACT) of more than 200 seconds to prevent clot formation.17

Then the stent graft is flushed with heparinized solution and advanced into the proximal neck. A repeat angiogram is recom- mended to confirm the position- ing of the device within the aorta.17

During device expansion, the systolic BP is lowered to 60 mm Hg using sodium nitroprusside to obtain precise deployment of the device and avoid migration due to forward blood flow. Adenosine may be administered to gain a 4- to 5-second cardiac arrest or a transfemoral venous pacing wire can be used for rapid pac- ing to prevent ejection of forward blood flow.13 The ventilator is also stopped shortly for device deployment in endotracheally intubated patients to eliminate motion artifact.17

After deployment, the stent graft is ballooned to decrease the possibility of endoleak.17

The nonocclusive balloon reduces movement of the graft, which can happen with the BP pushing forward. A final aor- togram is then performed to confirm that endoleak has not occurred.16 Distal pulses of the lower extremities are assessed to confirm a return to preopera- tive baseline and rule out any embolic events. The endovas-

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TEVAR TEVAR with dual branch device for residual aortic dissection after graft

replacement of ascending aorta for type A aortic dissection.

Reprinted with permission from Kuratani T. Best surgical option for arch extension of type B dissection:

the endovascular approach. Ann Cardiothorac Surg. 2014;3(3):292–299.

cular wires/catheters are then removed, the arteriotomy is repaired or closed with a closure device, and the patient is trans- ferred to the ICU for frequent neurologic and vascular assess- ments to detect complications such as stroke, spinal cord ischemia, or lower extremity ischemia.17,20

Complications Although there are advantages of TEVAR compared with tradition- al open repair, many potential complications still exist. These include spinal cord ischemia, stroke, renal complications, aor- toesophageal fistula (AEF) and aortobronchial fistula (ABF), ret- rograde type A dissections, post- implantation syndrome, ischemic bowel, and endoleak.9,11,15,21

Spinal cord ischemia. Spinal cord ischemia is thought to result from the interruption of the blood supply to the spinal cord, which may occur during deployment of the stent graft. (See Spinal cord ischemia risk fac- tors.) An endovascular approach may damage the iliac arteries

and compromise collateral flow to the anterior spinal artery.9

The incidence of spinal cord ischemia ranges from 2.5% up to 8% and remains a concern.2

Several factors may increase the risk of spinal cord ischemia.9

Most patients who develop spinal cord ischemia will do so within 24 hours of the procedure, with a median onset of 10 to 13 hours.22

Preventive strategies include maintenance of mean arterial pressure (MAP), the preven- tion of high intrathecal pressure through the use of lumbar drains, and the avoidance of high central venous pressures.21,23

Stroke. The incidence of stroke in patients undergoing TEVAR ranges from 1.2% to 6.9%.9 As the TEVAR procedure becomes more advanced and grafting extends into the aortic arch, the risk of stroke for these patients will increase further.24 During the procedure, guidewires within the aortic arch can potentially mobilize debris resulting in an embolic ischemic stroke.2 Stent deployment is associated with numerous microemboli.25 Thus,

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Thoracic endovascular aortic repair

patients are typically anticoagu- lated during the procedure and are maintained within therapeu- tic range using ACT monitoring.9

Postoperative anticoagulation should be held if the patient has a lumbar drain in place to reduce the possibility of epidural hema- toma; however, venous thrombo- embolism (VTE) prophylaxis is routine.8,26

Renal complications. Many patients with thoracic aneurysms often have chronic kidney disease. Contrast-induced nephropathy (CIN) and hypotensive injuries may result in further damage to renal function.2,27 Renal com- plications have been associated with a seven- to ninefold mortal- ity increase in patients with TAA repairs.27,28 Patients undergoing TEVAR require lifelong surveil- lance imaging with repeated contrast exposure to identify endoleak and graft migration.9

Therefore, the management of CIN in these patients remains complex.

Hydration with sodium bicar- bonate has been used to try to reduce CIN. Other proposals for management of these patients include stopping all angiotensin-

converting enzyme inhibitors and angiotensin II receptor blockers 48 hours prior to TEVAR, admit- ting patients with a creatinine greater than 2.0 mg/dL (normal serum creatinine level 0.5 to 1.2 mg/dL) for hydration preop- eratively, minimizing iodinated contrast media and/or using low or iso-osmolar contrast agents when possible, and avoiding nephrotoxic agents.5,28 The use of N-acetylcysteine, which is sometimes used to decrease renal complications in patients under- going cardiac catheterization, has not been proven effective in TEVAR.9 These patients require complex management pre- and postoperatively.

AEF and ABF. Although rare, AEF and ABF are devastating complications for patients under- going TEVAR.2,9,29,30

AEF is a fistula between the esophagus and the aorta that pres- ents as mid-thoracic chest pain, with a small episode of hemateme- sis followed by a brief interval, before massive hematemesis and exsanguination occur.29 Patients may also present with new-onset fever, fatigue, and anorexia.9 If an AEF is suspected, an emergent

Spinal cord ischemia risk factors9

Anatomic factors • length of aorta covered by graft

• previous abdominal aortic aneurysm repair

• number of patent lumbar arteries remaining

Procedural factors • intraoperative hypotension

• use of general anesthesia

• longer procedure times

Comorbidities • advanced age

• chronic obstructive pulmonary disease

• hypertension

• dyslipidemia

• cardiovascular disease

• renal insufficiency

CTA and esophagogastroduoden- oscopy should be obtained.2,29

Treatment with an endograft is the first-line therapy to stop exsangui- nation and limit bacterial contami- nation until surgery can be per- formed.9,29 Surgical interventions range from graft resection and replacement to esophagectomy but mortality remains very high for these patients.31

ABF is a fistula between the thoracic aorta and the adjacent pulmonary parenchyma or tracheobronchial tree.30 ABF presents with either intermittent or massive hemoptysis and is nearly always fatal if not diag- nosed or treated promptly.9,30

If suspected, a CTA should be obtained and emergent surgery performed.9

Retrograde type A dissec- tions. Aortic dissection results from a tear in the intima (inner lining) of the aorta. Because of the high pressure in the aorta, blood enters the media (middle layer) at the point of the tear and causes the tear to extend in either a forward direction (with the flow of blood) called anterograde dissections or in a backward direction (opposite the flow of blood) called retrograde dissections. Aortic dissections are further classified based on the site of the original tear (Debakey classification) and whether it involves the ascending aorta (Stanford classification).1 Type A dissection affects the ascend- ing aorta and arch, requiring immediate surgery, while Type B dissection begins in the descend- ing aorta and may be managed conservatively.6,14

Retrograde type A aortic dis- section is a rare but potentially

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fatal complication of TEVAR with an incidence of 1.3% to 3.4% and reported mortality of 42% to 57%.32 Retrograde dissection may occur intraoperatively or up to 7 years post procedure.32

Frequently, intraoperative diagno- sis is made based on angiography or thoracic endovascular echocar- diography.33 Dissection has been attributed to trauma from the deployment of the endograft into a diseased vessel as well as from wear and tear associated with the perpetual movement of the beat- ing heart.33 Clinically, patients most commonly present with new-onset chest pain or syncope and require an immediate CTA or magnetic resonance angiography (MRA). Once identified, these patients need emergent open sur- gical repair.9,33

Postimplantation syndrome. Postimplantation syndrome is an inflammatory response fol- lowing aortic repair that results in fever and malaise and often includes leukocytosis and eleva- tion of inflammatory mediators such as C-reactive protein.8,9

The clinical significance of this syndrome is not currently known and is often indistinguishable from an infection. It was initially thought to be a self-limiting reac- tion that resolves within 2 weeks of implantation; however, these patients have increased rates of renal insufficiency, prolonged lengths of stay, and higher mor- tality.8,9,26 Further studies are needed to establish diagnostic cri- teria and treatment guidelines.

Ischemic bowel. Mesenteric complications may result from aortic dissection or from emboli released during manipulation of the aorta during repair.2

The advantages of TEVAR include decreased

perioperative blood loss, operative time, and

morbidity, and shorter hospital stays.

Occlusion of the superior mesen- teric artery can cause ischemia of the small bowel. Although rare, this complication should be considered in any patient with elevated serum lactate lev- els or severe abdominal pain. If suspected, an exploratory lapa- roscopic exam of the peritoneal cavity should be performed.2

Endovascular stenting, open sur- gical superior mesenteric artery bypass, and/or surgical thrombec- tomy may be needed for reperfu- sion.9 Prognosis for these patients is grave and often results in hos- pital death.2

Endoleak. Endoleak is a complication of TEVAR that can happen at any time. It is defined as the persistence of blood flow outside the lumen of the graft in a segment treated by the graft, as determined by an imaging study.34 Incidence ranges from 5% to 25% at 30 days and 4% to 28% at 1 year with about 46% requiring additional treatment endovascularly.35 (See Types of endoleak.)

Types I and II are considered “high pressure” and require intervention. The presence or absence of an enlarging aneu- rysm sac strongly influences the decision to pursue or not pursue treatment.9 Type III endoleak is currently less common due to the improvements in grafts used today. A defective device, damage during delivery or balloon manip- ulation, or constant wear of the fabric against the endograft wires indicates the need for another endograft.9

Follow-up imaging surveillance of patients is done at 30 days, 6 months, 12 months, and then yearly to screen for endoleak post TEVAR.9,13 Since this requires significant doses of ionizing radiation with CTA and repeated exposure to contrast medium, ultrasound, and MRA without I.V. contrast, this may play a role in future surveillance protocols.9

Postoperative nursing considerations Because of the multiple serious complications that can occur after a TEVAR, a positive out- come for the patient relies on vigilant postoperative nursing assessments and prompt inter- ventions.

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Thoracic endovascular aortic repair

Neurologic assessment. Neurologic assessments are usually performed hourly for 8 hours and then every 2 hours, but can vary by institution.37

The assessment includes the Glasgow Coma Scale score, lower extremity strength, and pupil reaction.38 Assess the patient for signs and symptoms of meningeal irritation (stiff neck, headache, nausea, vomit- ing, photophobia) and report to the provider immediately.38 If the patient reports a headache, develops new neurologic deficits, or experiences a change in level of consciousness, the physician should be notified immediate- ly.11,37 If signs of brainstem her- niation are suspected (decrease in level of consciousness, irri- tability, confusion, abnormal posturing, and abnormal breath- ing pattern), activation of the emergency response team may be required.11

Assess for signs of embolic stroke, such as unilateral sen- sory or motor loss, amaurosis fugax (temporary loss of vision in one or both eyes due to a lack of blood flow to the retina), and aphasia, as well as changes in mentation or level of conscious- ness, facial symmetry, and pupil responses.12,38 Patients should

Types of endoleak9,36

receive VTE prophylaxis as pre- scribed.12

Hemodynamic monitoring. In the immediate postoperative period, management of intravas- cular volume and systemic BP is essential. If the BP is too high, anastomotic leaks or graft migra- tion may occur. On the other hand, hypotension may cause spinal ischemia, compromised renal perfusion, or infarction of vital organs.5,11,12 The MAP goal is usually kept between 75 and 85 mm Hg.9 However, the MAP goal should be obtained from the surgeon as it may be increased or decreased depending on the patient’s response. If needed, a low MAP can be treated with I.V. colloids (albumin), crystalloids (Ringer’s lactate solution), or neo- synephrine.8 A high MAP can be treated with sodium nitroprusside, alpha-1 adrenergic antagonists, and nonselective beta-blockers as needed.2

Pulmonary assessment. The critical care nurse should assess the patient’s pulmonary status and begin weaning the patient from the mechanical ventilator, if required, as soon as possible. It is important to evalu- ate the patient’s spontaneous breathing capability, respiratory rate, and respiratory pattern.6

Type I Leak around the proximal or distal attachment of the graft

Type II Retrograde branch flow into the aneurysm sac from collateral

vessels (lumbar or inferior mesenteric)

Type III Leak at the junction of graft due to a fabric tear or ineffective

sealing of overlapping graft joints

Type IV Blood flow into the aneurysm sac due to porous graft fabric

Type V No identifiable evidence of endoleak despite continued aneu-

rysm expansion

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Arterial blood gases should also be obtained and monitored per unit protocol. Oxygen saturation should be greater than 90% by pulse oximetry.6 Instruction on the use of the incentive spirom- eter is also important to help prevent atelectasis or pulmonary infection and should be encour- aged every hour while awake after extubation.

Pain management. Keeping the patient comfortable postoper- atively is also a high priority for the critical care nurse. Adequate pain management helps keep BP and heart rate under control. Pain should be assessed routinely, as persistent pain may indicate aortic dissection or impending rupture.2,11

Peripheral vascular assess- ment. Assessing the neurovascu- lar status of the lower extremities and monitoring the access sites for bleeding and hematoma is another important component of the nursing assessment.11 Assess for the classic signs of acute limb ischemia using the six “Ps”: pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia.38

Note the return of lower extrem- ity movement, sensation, and strength after waking from anes- thesia. If acute limb ischemia is suspected, contact the healthcare provider immediately. Ischemia may progress to tissue necro- sis and gangrene within a few hours.38

Gastrointestinal and renal assessments. Abdominal assess- ment and monitoring of urine output is important because embolization can occur to the visceral and renal arteries. Nursing interventions include measurement and monitoring

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of intra-abdominal pressure and monitoring for signs and symp- toms of acute ischemic bowel. Contact the surgeon immediately if the patient experiences severe abdominal pain, nausea, vomit- ing, or diarrhea in the absence of abdominal distension. Check the patient’s lactate level for worsen- ing metabolic acidosis indicating hypoperfusion to the gut.2,12

Assess the patient's hydration status and serum electrolyte results and closely monitor urine output.39 Additional abdomi- nal radiologic imaging may be needed.12

Consideration of postoperative nutritional requirements is also necessary. When the patient has fully recovered from anesthesia and bowel sounds have returned, ice chips may be introduced before advancing to clear liquids and finally solids as tolerated.12

The American Society for Parenteral and Enteral Nutrition guidelines recommend starting enteral nutrition for all appropri- ate patients within 24 to 48 hours of admission to the ICU. If hemo- dynamic instability or high vaso- pressor needs prohibit enteral feeding after 7 days, parenteral feeding may be required.8,40

Site infection. The nurse should assess all incision sites for signs and symptoms of infec- tion, which include erythema, warmth, edema, and drainage.6

Monitor for leukocytosis daily. The patient’s temperature should also be assessed every 2 hours, or per the unit protocol. Meticulous incisional care should be per- formed by the critical care nurse to prevent infection.

Patient and family support. Often, aortic pathologies are

Critical care nurses can support families

by providing information, interpreting medical

terminology, and explaining procedures.

emergent situations. Seeing their loved one in such a condition can be upsetting to family mem- bers. Critical care nurses can support families by providing information, interpreting medi- cal terminology, and explaining procedures. When critical care nurses communicate information in a caring and compassionate manner, it significantly enhances the well-being of the family.40

The critical care nurse is often the liaison relaying feedback between the medical staff and the family, recommending family meetings as necessary.

Patient discharge instructions Teach the patient to monitor the access sites for signs of infection or bleeding. Review pain manage- ment strategies with the patient and family. Explain to the patient that sodium can affect their BP control, so they should try to maintain a low-sodium diet. Instruct the patient to walk at least four times a day and avoid lifting more than 10 lb (4.5 kg) for 2 weeks. Driving can resume 2 weeks after discharge. Teach patients to seek care immediately if they have a sudden decrease in strength, sensation, temperature, or experience a change in color of the lower extremities, sudden swelling and acute pain in one or both groins, and/or sudden onset of chest or back pain.12

The critical care nurse should also stress the importance of monitoring of the stent graft by CTA at 1 month, 6 months, and 12 months after implant, and then annually.12,13 The nurse should explain that the stent graft is not a cure and complications, such as endoleak, may arise in the future, which could require a second endovascular procedure. Stressing adherence to the annual surveillance is paramount.

Conclusion Although TEVAR has emerged as the treatment of choice for patients with TAAs, it is still a high-risk procedure with many complex complications that con- tribute to high morbidity and mortality. Knowledgeable critical care nurses are instrumental in the proper care, recovery, and discharge of patients who have undergone a TEVAR. ■

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Thoracic endovascular aortic repair

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Geraldine M. O’Leary is a clinical instructor at La Salle

University School of Nursing and Health Sciences,

Philadelphia, Pa., and a member of the Nursing2020

Critical Care Editorial Board.

The author has disclosed no financial relationships

related to this article.

DOI-10.1097/01.CCN.0000668568.61132.75

32 l Nursing2020CriticalCare l Volume 15, Number 4 www.nursingcriticalcare.com