Laparoscopic aortic reinforcement and endovascular graft placement in swine: a new external wrap

OBJECTIVE: To evaluate the feasibility, safety, and histological response of laparoscopic external aortic wrap implantation in conjunction with an endovascular stent/stent-graft placement in the infrarenal aorta in a porcine model. METHODS: Seven swine underwent laparoscopic retroperitoneal placement of a custom-made Dacron fabric wrap placed around the infrarenal aorta to create a landing zone for an endovascularly placed aortic stent/stent-graft. RESULTS: Technical success was achieved in all animals without any major complications. Follow-up ranged from 1 to 4 weeks. At necropsy, the external wraps were well incorporated into the adventitia, and the stents/stent-grafts were well incorporated into the intima. Small patches of medial necrosis of the aortic wall were observed in one animal in the stent model and in two animals in the stent-graft model. There was no transmural necrosis observed. CONCLUSIONS This adjunct technique, an external wrap around the infrarenal aorta combined with endovascular grafting, is feasible and deserves further studies into how it may be used to facilitate endovascular repair of aortic aneurysms. CLINICAL RELEVANCE: We hypothesize that our new device could provide capability of altering the proximal neck morphology of abdominal aortic aneurysm and reinforcement to the aortic wall. This, in turn, could improve eligibility for endovascular aneurysm repair and prevent or treat type I endoleak and graft migration. Future investigations will involve evaluation of the long-term effect of the external aortic wrap on the integrity of the aortic wall in an animal model and testing the clinical usefulness of this new technique.     

经颈动脉腔内技术重建主动脉弓治疗Stanford A型夹层动脉瘤(附1例报告)

目的探讨血管腔内技术重建主动脉弓治疗升主动脉、主动脉弓病变的可行性。方法2005年,对1例StanfordA型夹层动脉瘤,腔内修复主动脉病变之前做右颈总动脉-左颈总动脉-左锁骨下动脉的旁路术;经右颈总动脉将修改的分叉支架型血管主体放入升主动脉,长臂位于无名动脉。短臂应用延长支架型血管延伸至降主动脉。通过腔内技术重建主动脉弓实现累及升主动脉和主动脉弓主动脉病变的微创治疗。结果腔内修复术后移植物形态良好,血流通畅,病变被隔绝,脑、躯干、四肢循环稳定。无严重并发症。结论该手术方案设计合理、技术可行。可能成为复杂胸主动脉病变新的腔内治疗模式。     

Simultaneous abdominal aortic replacement and thoracic stent-graft placement for multiple aortic aneurysms: report of a case

Patients with aneurysmal disease involving both the thoracic and abdominal aorta have historically required simultaneous or sequential conventional operations. Staged operations were generally preferred, but we experienced that a patient had rupture of the second aneurysm after he finished initial treatment for the first aneurysm. We have implemented simultaneous operation using thoracic stent-graft placement. A 78-year-old male who had multiple aortic aneurysm involving both the thoracic and abdominal aorta underwent conventional abdominal aortic replacement with endovascular stent-graft placement into the distal arch of the thoracic aorta under fluoroscopic guidance. The stent-graft was composed of two units of self-expanding stainless-steel Z stent covered with an thin wall woven Dacron graft. Postoperative aortography showed no stent migration and no endoleak. Simultaneous abdominal aortic replacement and deployment of a thoracic stent-graft may be a valuable treatment option for these patients. However, careful long term follow up is necessary to prove the value and the effects of the endovascular treatment.     

Endovascular repair of acute type B aortic dissection: early and mid-term results

OBJECTIVE: To evaluate early and mid-term results of endovascular repair of acute type B aortic dissection by stent graft. METHODS: From June 2001 to May 2005, 63 patients with acute type B aortic dissection underwent stent graft implantation. The study included 59 men and 4 women with an average age of 50.4 +/- 11.4 years (range, 31-80 years). Four patients underwent stent-graft implantation in the acute phase. Fifty-nine patients with acute type B dissection underwent stent-graft implantation 2 weeks after the onset of dissection. All patients were followed up from 1 to 47 months (average, 11.7 +/- 10.6 months). The clinical data of the patients were analyzed. RESULTS: The primary tear was incompletely sealed in three cases. The incidence of incomplete seal was 4.8%. Ascending aortic dissection occurred in three cases. One occurred during operation. The other two occurred at 1 day and 10 months after stent-graft implantation. Two patients died within 30 days after operation. One died of rupture of the ascending aortic dissection. The other one died of acute renal failure. The 1-month mortality was 3.2%. Four patients underwent a second stent-graft implantation before discharge. One year after stent-graft implantation, complete thrombosis of the false lumen in the thoracic aorta was achieved in 98.4% of patients, and the maximum diameter of the descending aorta decreased 11.2% +/- 7.3%. Three patients died within the follow-up time. Mortality during the follow-up period was 4.8%. One patient died of peptic ulcer hemorrhage. Another one died of rupture of the ascending aortic dissection. The third one died of unknown reasons. The actuarial survival curve by the Kaplan-Meier method showed a 4-year survival rate of 89.4%. CONCLUSIONS: Early and mid-term results showed that endovascular repair was effective in treatment of acute type B aortic dissection. With the enrichment of doctors' experience and refinement of the device, better results are expected in the future.     

Thoracic endovascular stent grafting inhibits aortic growth: an experimental study.

OBJECTIVE: Dilatation of the aorta at the landing zone site may be exaggerated by the radial force of stent grafts potentially limiting long-term results of endovascular therapy. We evaluated growth patterns and morphology of the thoracic aorta in young piglets after thoracic stent-graft placement. METHODS: Eight domestic piglets (37+/-2 kg) had an endovascular stent graft placed in the proximal descending thoracic aorta using retroperitoneal access. At implantation, the stent was oversized by 10%. Aortic size was documented after thoracotomy by intraoperative measurement and angiography. Subsequently the piglets were grown to adult size (181+/-42 kg). At explantation 6-15 months later, CT scan and surgical evaluation for endoleaks, defined as perigraft flow, was performed. Histopathological assessment of the explanted aorta was performed in stented and non-stented segments and compared to five normal porcine aortas. RESULTS: No endoleak (perigraft flow) or stent migration occurred even in 230kg pigs. The stent grafts expanded to full size, but there was no further growth in the stented area. The aortic diameter increased significantly by 32+/-9% 1cm proximal to the stents (p=0.0012) and by 45+/-13% 1cm distal to the stents (p=0.0033). The stented area grew less than the proximal (p=0.0011) and distal aorta (p<0.0001). In all pigs, the distal aorta was larger than the proximal overstented segment. Histology of the stented aorta showed significant thickening of the intima (p=0.018) and media (p=0.006) with neointimal formation and segmental fibrosis of the inner 1/3 of the media with loss of smooth muscle cells and compression of the elastic fibers but normal architecture in the outer 2/3 of the media. CONCLUSIONS: Endovascular stent grafting may inhibit growth of the nonatherosclerotic normal aorta and lead to intimal hyperplasia and focal fibrosis in the inner media part adjacent to the stent. Stent-graft interaction with aortic tissue over time is important and should receive more detailed evaluation. Testing this interaction in an animal model of nonatherosclerotic dilative aortic disease could be of great interest.     

Value of intravascular ultrasound for endovascular stent-graft placement in aortic dissection and aneurysm

BACKGROUND: Endovascular stent-graft placement is a new concept for the treatment of aortic dissection and aneurysm. Intravascular ultrasound (IVUS) with established diagnostic features may be instrumental in guiding endovascular procedures. METHODS: We performed IVUS and digital angiography before, during, and after implantation of 47 stent grafts in 40 patients with Stanford type B dissection (26 patients, 28 stent grafts), thoracic aneurysm (9 patients, 11 stent grafts), and abdominal aneurysm (5 patients, 8 stent grafts). RESULTS: IVUS could clearly identify the aortic anatomy and differentiate between true and false lumen in all cases of dissection. In four patients with type B dissection extending from the thoracic to the abdominal aorta the true lumen was exclusively identified by IVUS, and thus, essential for safe execution of the procedure. In another patient stent-graft placement in the aorta was optimized by covering a second entry detected by IVUS, but undetected by angiography. The site of stent implantation, the true and false lumen, as well as entry and reentry were always identified in both thoracic and abdominal aorta. In comparison with angiography, IVUS information led to additional balloon molding due to incomplete stent apposition in seven cases. CONCLUSIONS: As an adjunctive imaging modality IVUS is likely to improve stent-graft placement in aortic type B dissection, especially in patients with abdominal extension.     

Endovascular repair after stent elephant trunk procedure for extensive thoracic aortic aneurysm

Hybrid surgical-endovascular procedure was conducted in a 46-year-old male with extensive thoracic aortic aneurysm. Ascending aorta and arch replacement combined with stent elephant trunk implantation was performed first. An open stent-graft was implanted into the descending aorta. One month later, endovascular repair was conducted. Postoperative CTA showed total coverage of the descending aorta by stent-grafts and the descending aortic aneurysm was totally thrombo-excluded. Stent elephant trunk may be a better alternative to conventional elephant trunk in hybrid surgical-endovascular approaches in treatment of extensive thoracic aortic aneurysm.     

钝性外伤后胸主动脉扩张性病变的临床分析

目的 总结钝性外伤后胸主动脉扩张性病变诊疗经验.方法 回顾性分析12例钝性外伤后胸主动脉扩张性病变的临床资料,其中主动脉夹层(Stanford B型)8例以及降主动脉假性动脉瘤4例.术前螺旋CT血管造影及术中数字血管减影造影对病变进行评估,待严重合并症稳定后行腔内支架型人工血管植入术.术后3、6、12个月以及其后每年随访CTA明确治疗效果.结果 11例行腔内支架型人工血管植入术,另1例未及手术死亡.所有手术患者均获技术成功,完全或部分遮蔽左锁骨下动脉6例,支架释放后即刻造影发现内漏3例,2例球囊扩张后内漏消失,1例仅给予随访.共9例获随访(B型主动脉夹层6例、降主动脉假性动脉瘤3例),均正常生存,未出现左上肢缺血症状及神经系统阳性体征,CTA检查示近远端主动脉无新发夹层或动脉瘤,无内漏、截瘫以及支架移位等并发症.结论 钝性外伤后胸主动脉损伤多位于主动脉峡部,待重要脏器合并症稳定后行腔内支架型人工血管治疗有效可行,安全性高.     

Transesophageal echocardiography-guided algorithm for stent-graft implantation in aortic dissection

OBJECTIVE: Endovascular stent-graft placement is replacing traditional surgery in type B aortic dissection. Usually stent-graft implantation is performed under fluoroscopic and angiographic guidance, but this relatively new procedure is still burdened with some complications. We investigated the value of a developed algorithm based on transesophageal echocardiography (TEE) for guiding stent-graft implantation in type B aortic dissection. METHODS: Forty-two patients with type B aortic dissection (chronic in 28 patients with aneurysmal dilatation of the false lumen, and acute complicated in 14 patients) underwent endovascular stent-graft reconstruction of the descending thoracic aorta. TEE was always performed after angiography. TEE-induced variations of the procedure, based on the algorithm, were compared with initial angiography-based decisions. RESULTS: TEE was decisive for guidewire repositioning (not possible with fluoroscopy) from the false to the true lumen in 3 patients and for correct guidewire entrance in an elephant trunk prosthesis in another patient. After stent-graft implantation color Doppler TEE enabled detection of proximal peri-stent leaks in 13 patients, whereas only 6 (46%) of the 13 leaks were detectable at angiography (P = .008). Most leaks were subsequently eliminated with balloon dilation or further stent grafting. Pulsed Doppler TEE was also useful for differentiating true leaks (13 patients) from Dacron porosity (7 patients). A pulsed-Doppler velocity cutoff value of 50 cm/s enabled differentiation of Dacron porosity (characterized by slow blood flow) from true peri-stent leak (fast flow). After stent-graft implantation TEE demonstrated new intimal tears in the thoracic aorta in 7 patients, whereas only 2 of the 7 new tears were detectable at angiography (P = .024); in 6 of 7 patients the new distal tears were subsequently resolved with placement of additional stents, whereas in a patient with Marfan syndrome new proximal tears determined a type I endoleak, which could not be resolved. Overall, TEE furnished decisive information additional to angiography in determining successful procedural changes in 16 of 42 patients (38%). There were no in-hospital deaths, and pre-discharge spiral computed tomograms showed a good outcome of stent-graft implantation in 37 of 42 patients (88%), with 5 residual type I endoleaks, all previously detected with TEE but impossible to eliminate with either balloon molding or further stent implantation. All but 2 patients (95%) are currently alive at mean follow-up of 30 +/- 18 months. CONCLUSIONS: TEE algorithm is an easy and useful tool in the operating room to guide correct stent-graft positioning in type B aortic dissection.     

Midterm results of stent-graft repair for thoracic aortic aneurysms: computed tomographic evaluation

Midterm observation of endovascular surgery using a fabric-covered stent graft for thoracic aortic aneurysms is discussed with postoperative follow-up findings based on regularly performed thoracic computed tomography (CT). From 1996 to 1999, 20 patients with thoracic aortic aneurysm underwent stent-graft placement in our hospital. One year follow-up CT results after placement were obtained for 17 patients. The CT scans found that there were both thrombosis and size reduction of aneurysm in 8 patients (46%), thrombosis without size reduction in 2 (13%), a new ulcerlike projection (ULP) in 3 (19%), persistent minor endoleakage in 2 (13%), a new endoleak in 1 (6%), and a recurrent endoleak from intercostal arteries in 1 (6%). The new ULP formation seemed to be a peculiar problem stemming from an intimal injury caused by edges of the stent. Therefore, we recently adopted a new spiral stent instead of the previous stent to avoid the injury. The new endoleak suggested that aneurysmal thrombosis without size reduction could cause the aneurysm to develop recurrent endoleaks. From these findings, we concluded that midterm observation of stent-graft repair for thoracic aortic aneurysms did not give satisfactory results. In order to improve the results of endovascular surgery using stent-grafts, we need to develop safer stent grafts with a reliable design to prevent endoleaks and to avoid intimal injury of the aorta. We also hope to develop effective technologies that can accelerate organization of thrombus in the aortic aneurysm after stent-graft placement.     

Thoracic stent-graft

The stent-graft is a device constructed from a stent and vascular graft and is inserted by means of an interventional procedure under imaging guidance. In 1986, Balko et al. reported the first stent-graft experiment, in which a Z stent covered with polyurethane was inserted into an animal aorta. In the early 1990s, Parodi et al. reported clinical introduction of the stent-graft for abdominal aortic aneurysm. In comparison to the abdominal aortic stent-graft, the thoracic stent-graft has several disadvantages, including difficulties associated with the aortic arch curvature and the relatively large caliber of the stent-graft, and the risk of central nervous system or spinal complication. However, the thoracic stent-graft is advantageous because of minimal procedural invasiveness in comparison to surgical graft replacement. In 1994, Dake et al. reported transluminal placement of an endovascular stent-graft for thoracic aortic aneurysm, and Kato et al. reported use of a stent-graft for aortic dissection and suggested that the stent-graft could be considered an alternative to surgical treatment.     

急性Stanford B型主动脉壁间血肿的治疗

目的 探讨急性Stanford B型主动脉壁间血肿的治疗方法和预后.方法 总结2001年1月至2008年3月收治的Stanford B型主动脉壁间血肿29例的临床资料.依据以下标准将患者分为三组:(1)有主动脉硬化性穿透性溃疡;(2)血压不易控制;(3)持续胸背部不适.符合上述任何一项的患者入选为腔内治疗组(13例),其余患者归入药物治疗组(16例).腔内治疗组采用降主动脉覆膜支架置入术;药物治疗组只接受降压、止痛等内科保守治疗.结果 本组29例患者均获随访,随访时间6～89个月,平均(19±16)个月,药物治疗组16例患者3例病情进展为夹层予支架治疗,2例突发主动脉破裂而死亡,疾病恶化率为31.25%,死亡率为12.5%;腔内支架治疗组13例患者随访期间未见夹层复发、支架移位及其他并发症.总共置入覆膜支架16个.结论 急性Stanford B型主动脉壁间血肿疾病恶化率高,腔内覆膜支架置入术是积极有效的治疗方法.     

Endovascular management of acute blunt traumatic thoracic aortic injury: a single center experience

BACKGROUND: Traumatic injury of the thoracic aorta is a life-threatening complication in patients who sustain deceleration or crush injuries. The magnitude of force necessary to cause blunt thoracic aortic injury results in a high proportion of concomitant injuries, posing a significant challenge for prioritizing management. Open surgical mortality is increased in the presence of coexisting head, lung, and abdominal injuries. Spinal cord ischemia may occur following aortic cross-clamping and operative hypotension. Endovascular stent-graft placement offers a safe, effective, and timely treatment option. The aim of this study was to assess our single center experience of endovascular repair following acute blunt traumatic aortic injury. METHODS: Data from thirteen consecutive patients (mean age, 43.2 years; range, 16 to 84 years) with acute blunt traumatic aortic injury treated by endovascular stent-graft insertion between October 2001 and March 2007 was prospectively collected. Demographics, injury characteristics, technique, and complications were recorded. Follow-up data consisted of computed tomographic angiography and plain chest radiography at regular intervals. Mean and median follow-up after stent-graft implantation were 28.9 and 29 months, respectively. RESULTS: All patients underwent endovascular repair within a median of 9 hours from hospital presentation. Two patients underwent carotico-carotid bypass immediately prior to endovascular stenting during a single anesthetic. Stent-graft implantation was technically successful in all patients. No patient required conversion to open surgical repair of the acute blunt traumatic aortic injury. Procedure-related paraplegia was zero. Complications included proximal migration of initial stent-graft in one patient and iliac artery avulsion in another patient with consequent ilio-femoral bypass. The median hospital stay was 17 days. There were no in-hospital deaths. CONCLUSION: Endovascular repair is evolving as the procedure of choice for acute blunt traumatic aortic injury. Treatment of lesions that extend into the aortic arch is feasible with extra-anatomical bypass. In our study, endovascular repair of blunt traumatic aortic injury is a safe procedure with low morbidity and a mortality rate of zero.     

Stent-graft repair of the thoracic aorta: short-term results

The purpose of this study was to evaluate clinical feasibility and immediate outcome of stent-graft repair of the thoracic aorta. From December 1999 to January 2001, a total of 14 patients underwent stent-graft repair of the thoracic aorta. The underlying etiologies were traumatic rupture of the aortic isthmus in four cases, Stanford type B dissection in four, thoracic aortic aneurysm in three, penetrating atherosclerotic ulcer in two cases, and postoperative aortoesophageal fistula in one case. Stent-graft placement was performed under angiographic control in all cases in association with transesophageal echography in seven cases. The procedure was performed under emergency conditions in five cases. Thirteen patients presented contraindications for surgery. stent-graft placement was succesful in all cases. No further surgery has been performed in any case. Thus we conclude that endovascular treatment of the thoracic aorta using stent grafts is a promising therapeutic modality in patients with contraindications for conventional surgical treatment.     

Thoracic stent-graft herniation through the aortic wall in a case of lung cancer

A 67-year-old man had left upper lung cancer with invasion into the descending aorta. He underwent pre-emptive thoracic endovascular aortic repair using a Valiant Navion followed by left lung upper lobectomy with resection of the aortic wall. Because of continuous bleeding, he underwent re-thoracotomy. Since the surgically resected aortic wall was largely cleaved, bleeding around the stent-graft that herniated into the left pleural cavity was observed. Re-thoracic endovascular aortic repair using a GORE TAG was immediately performed to prevent further stent-graft herniation and impending lethal haemorrhage. It may be necessary to consider reinforcement of the resected aortic wall to prevent thoracic endovascular aortic repair-related complications.     

Endovaskulärer Aortenklappen- und Aszendensersatz

Currently there is no standard endovascular treatment option for ascending aortic aneurysms or dissection combined with aortic valve malformations. Our aim was to design a composite endovascular device consisting of a transcatheter aortic valve prosthesis and integrated thoracic aortic stent graft. The endovascular composite valve graft design is based on five integrated concepts: 1) individualization of prosthesis size according to the anatomy, 2) intraoperative coupling of both components, 3) free diastolic coronary perfusion, 4) distribution of the radial force to three anatomical structures, namely the aortic valve annulus (zone  A), the sinotubular junction (zone B) and the distal ascending aorta (zone C) and 5) single stage implantation. The short distance between the coronary arteries and zone B and significant angulation between the planes of zones B and C must be considered in the composite valve graft designing process. The novel conduit device will enable simultaneous endovascular repair of aortic valve malformations and ascending aorta aneurysms or dissection.     

A standardized aortic aneurysm model for the assessment of endovascular stent-graft technology

Reliable models of aortic aneurysms are required to test endovascular stent-graft technology prior to human use. We describe the creation of a standardized prosthetic aneurysm in an ovine model to assess endovascular technology. In an adult ovine model under general anesthesia, a polyester sphere measuring 6 cm across was sutured onto the infrarenal aorta following aortotomy. Two weeks later an endovascular stent-graft was deployed in the aorta. Exclusion was confirmed on monthly ultrasound duplex and during angiography at three months and under terminal anesthesia at six months. Autopsy along with histology of the specimen were then performed. A total of 10 sheep underwent aneurysm implantation. Nine received a straight tube endovascular stent-graft (Lombard Medical, Abingdon, Oxon, UK) and seven completed the study. Five prosthetic aneurysms shrank during serial imaging with duplex ultrasound and angiography. However, two remained the same size. One of these had a type I endoleak whereas the other had endotension (type I endoleak confirmed at autopsy). This animal model provides a reliable and reproducible method of creating prosthetic aneurysms for assessing endovascular stent-grafts. It was possible to assess aneurysm exclusion non-invasively using duplex ultrasound. Aneurysms effectively excluded from the circulation shrank whereas those with an endoleak did not.     

腔内支架人工血管治疗主动脉弓部动脉瘤

目的 探讨腔内支架人工血管治疗主动脉弓部动脉瘤的基本方法。方法 采用国产腔内支架人工血管治疗主动脉弓部动脉瘤患者46例,其中主动脉瘤累及主动脉弓中部23例(50％),单纯累及弓降部22例(48％),累及胸降主动脉1例(2％)。选择支架直径是夹层破裂口或瘤口近端相应部位主动脉直径宽的1．15～1．20倍。支架近端直径34～38mm,长度90～120mm。支架材料为国产形状记忆镍钛合金。结果 支架释放成功45例(98％),无远端动脉并发症发生。支架释放后即刻封闭瘤口或破裂口43例(96％),早期内漏2例(4％)。夹层真腔全部恢复正常。急性期患者中转手术1例,死亡2例。术后43例患者获随访,随访时间1～23个月,远期内漏3例(7％),但所有随访患者均恢复正常生活。结论 腔内支架人工血管可用于主动脉弓部动脉瘤的治疗,其治疗的长期效果还需进一步观察。     

Overdrive pacing for endovascular repair of an aortic arch aneurysm

The endovascular treatment of aortic arch aneurysms is a relatively new technique and is associated with significant surgical and anesthetic challenges. We report a case of a 77-year-old patient with an aortic arch aneurysm at the level of the isthmus, measuring 4.9 × 6.5 cm. The aneurysm involved the origin of the left subclavian and vertebral arteries. The arch was of the bovine type and the left vertebral artery came directly off the aorta. The patient underwent an uneventful open left carotid-to-subclavian bypass several days before the aortic repair. During the endovascular surgery, a stent-graft was deployed just distal to the innominate trunk. Endoleak was noted at the inferior aspect of the stent-graft, which failed to seal with placement of an extension stent-graft. The surgeon then chose to employ a Palmaz stent, to seal the endoleak. Balloon expansion in the ascending aorta was required in order to properly seat the Palmaz stent. Overdrive pacing at a rate of 220 beats·min^?1, which lowered the systolic blood pressure (SBP) to 40s mmHg was used during this process after connecting the patient to a Zoll defibrillator with external pads. The Palmaz stent was successfully deployed at the proximal end of the previously deployed stent-graft, using a Tyshak balloon. The patient reverted to normal sinus rhythm with no evidence of ischemia at the conclusion of the overdrive pacing. No endoleak was appreciated after the Palmaz stent was placed.     

Observations on the failure of stent-grafts in the aortic arch.

INTRODUCTION: The results of endovascular stent-grafts in the abdominal aorta and descending thoracic aorta have been encouraging. Expanding the use of thoracic stent-grafts in to the aortic arch has been associated with increasing numbers of complications. Recently isolated cases of stent-graft collapse have been reported. METHODS: This was a multi-centre European case series. Data was collected retrospectively on seven patients from five experienced endovascular centres with thoracic stent-graft collapse. RESULTS: Of the seven patients four were treated for traumatic aortic rupture. Six were male, median age 33 (range 17-54) years. During the ensuing 2 months all patients suffered stent-graft collapse. This was symptomatic in 3 patients and the rest were identified on CT. Endovascular management was possible in 6/7 patients using either a balloon expandable stent (n=6) or further stent-graft (n=1). Two patients had persistent type I endoleak despite treatment. Two of the 7 patients died, both of which presented with symptomatic thoracic stent-graft occlusion. Both deaths were a direct result of stent-graft collapse. CONCLUSIONS: Thoracic stent-graft collapse may be asymptomatic underscoring the importance of stent-graft surveillance. Endovascular management of collapse is possible in most cases using a large balloon expandable stent. Symptomatic collapse is associated with high morbidity and mortality.