Thoracic endovascular aortic repair (TEVAR) has become an attractive alternative treatment option for many patients with specific thoracic aortic disease. New devices and advanced image-guided procedures are continuously expanding the indications and improve neurological outcomes. Hemodynamic management of these patients is a critical aspect in reducing neurological deficit and it is different compared to patients undergoing open thoracic aortic operations. There are two different phases of blood pressure management for patients with thoracic aortic disease. Before and during the critical steps of TEVAR anti-impulsive therapy facilitates safe positioning and stent deployment. After stent grafts are deployed, controlled hypertensive blood pressure levels are achieved to avoid spinal cord ischemia. This precise blood pressure strategy is essential to ensure a safe procedure and good long-term results. 1. Introduction Since 1991, Parodi et al. described the first endovascular exclusion of an abdominal aortic aneurysm ; the technique and devices evolved rapidly and thoracic aortic diseases were involved. Dake et al. introduced in 1994 the use of stent grafts for the treatment of the descending thoracic aortic aneurysm for high risk patients  and Shimono et al. in 1998 for an acute type A aortic dissection . Since the first stent grafts for thoracic endovascular aortic repair (TEVAR) were approved and become commercially available in 2005, feasibility and successful utilization of this technique have been established. Endovascular repair in selected patients with complex aortic pathologies has now lower perioperative mortality and complications compared with open surgical repair [4–6]. Besides the interventional treatment, in patients with thoracic aortic disease stringent antihypertensive therapy, lipid profile optimization, smoking cessation, and reduction of other atherosclerosis risk factors are recommended . This accompanying medical therapy has evolved and their benefits were studied on the effect of aneurysm growth. Furthermore, blood pressure management plays a critical role during the TEVAR procedure itself and demands a close collaboration between the surgeon and anesthesiologist as well as an understanding of each specialty and interventional steps. The aim of this is to provide a concise update on various aspects of thoracic endografting followed by a more comprehensive review of the antihypertensive medications used for hemodynamic management of the patients with aortic disease and during the endovascular procedure. 2. Preoperative
M. D. Dake, D. C. Miller, C. P. Semba, R. S. Mitchell, P. J. Walker, and R. P. Liddell, “Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms,” The New England Journal of Medicine, vol. 331, no. 26, pp. 1729–1734, 1994.
T. Shimono, N. Kato, T. Tokui et al., “Endovascular stent-graft repair for acute type A aortic dissection with an intimal tear in the descending aorta,” Journal of Thoracic and Cardiovascular Surgery, vol. 116, no. 1, pp. 171–173, 1998.
A. Khoynezhad, C. E. Donayre, J. Smith, G. E. Kopchok, I. Walot, and R. A. White, “Risk factors for early and late mortality after thoracic endovascular aortic repair,” Journal of Thoracic and Cardiovascular Surgery, vol. 135, no. 5, pp. 1103.e1–1109.e4, 2008.
D. Cheng, J. Martin, H. Shennib et al., “Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease a systematic review and meta-analysis of comparative studies,” Journal of the American College of Cardiology, vol. 55, no. 10, pp. 986–1001, 2010.
A. Khoynezhad, C. E. Donayre, B. O. Omari, G. E. Kopchok, I. Walot, and R. A. White, “Midterm results of endovascular treatment of complicated acute type B aortic dissection,” Journal of Thoracic and Cardiovascular Surgery, vol. 138, no. 3, pp. 625–631, 2009.
L. F. Hiratzka, G. L. Bakris, J. A. Beckman, et al., “2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine,” Circulation, vol. 121, no. 13, pp. e266–e369, 2010.
A. Khoynezhad, R. Celis, M. Hashemzadeh, M. R. Movahed, and Z. Jalali, “Current status of thoracic endografting and its adjunctive pharmacology,” Expert Opinion on Pharmacotherapy, vol. 10, no. 17, pp. 2871–2881, 2009.
F. H. W. Jonker, F. J. V. Schlosser, A. Geirsson, B. E. Sumpio, F. L. Moll, and B. E. Muhs, “Endograft collapse after thoracic endovascular aortic repair,” Journal of Endovascular Therapy, vol. 17, no. 6, pp. 725–734, 2010.
J. Dumfarth, M. Michel, J. Schmidli et al., “Mechanisms of failure and outcome of secondary surgical interventions after thoracic endovascular aortic repair (TEVAR),” The Annals of Thoracic Surgery, vol. 91, no. 4, pp. 1141–1146, 2011.
R. K. Greenberg, S. Haulon, S. O'Neill, S. Lyden, and K. Ouriel, “Primary endovascular repair of juxtarenal aneurysms with fenestrated endovascular grafting,” European Journal of Vascular and Endovascular Surgery, vol. 27, no. 5, pp. 484–491, 2004.
A. Khoynezhad, P. Upadhyaya, and M. J. Kruse, “Spinal cord injury and stroke following thoracic endovascular aortic repair: a risk analysis and review of the literature,” Italian Journal of Vascular and Endovascular Surgery, vol. 14, no. 3, pp. 221–229, 2007.
W. A. Lee, J. S. Matsumura, R. S. Mitchell, et al., “Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the society for vascular surgery,” Journal of Vascular Surgery, vol. 53, no. 1, pp. 187–192, 2011.
J. Buth, P. L. Harris, R. Hobo 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,” Journal of Vascular Surgery, vol. 46, no. 6, pp. 1103.e2–1111.e2, 2007.
A. Khoynezhad, C. E. Donayre, H. Bui, G. E. Kopchok, I. Walot, and R. A. White, “Risk factors of neurologic deficit after thoracic aortic endografting,” Annals of Thoracic Surgery, vol. 83, no. 2, pp. S882–S889, 2007.
B. A. Ehlert, C. A. Durham, F. M. Parker, W. M. Bogey, C. S. Powell, and M. C. Stoner, “Impact of operative indication and surgical complexity on outcomes after thoracic endovascular aortic repair at National Surgical Quality Improvement Program Centers,” Journal of Vascular Surgery, vol. 54, no. 6, pp. 1629.e1–1636.e1, 2011.
G. Melissano, A. Kahlberg, L. Bertoglio, and R. Chiesa, “Endovascular exclusion of thoracic aortic aneurysms with the 1- and 2-component Zenith TX2 TAA endovascular grafts: analysis of 2-year data from the TX2 pivotal trial,” Journal of Endovascular Therapy, vol. 18, no. 3, pp. 338–349, 2011.
L. Canaud, K. Hireche, J.-P. Berthet, P. Branchereau, C. Marty-Ané, and P. Alric, “Endovascular repair of aortic arch lesions in high-risk patients or after previous aortic surgery: midterm results,” Journal of Thoracic and Cardiovascular Surgery, vol. 140, no. 1, pp. 52–58, 2010.
S. W. Stavropoulos and J. P. Carpenter, “Postoperative imaging surveillance and endoleak management after endovascular repair of thoracic aortic aneurysms,” Journal of Vascular Surgery, vol. 43, supplement, no. 2, pp. A89–A93, 2006.
M. I. Turina, H. Shennib, J. Dunning et al., “EACTS/ESCVS best practice guidelines for reporting treatment results in the thoracic aorta,” European Journal of Cardio-thoracic Surgery, vol. 35, no. 6, pp. 927–930, 2009.
G. Mancia, R. Fagard, K. Narkiewicz, et al., “2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC),” European Heart Journal, vol. 34, pp. 2159–2219, 2013.
T. Suzuki, E. M. Isselbacher, C. A. Nienaber et al., “Type-selective benefits of medications in treatment of acute aortic dissection (from the International Registry of Acute Aortic Dissection [IRAD]),” The American Journal of Cardiology, vol. 109, no. 1, pp. 122–127, 2012.
N. H. Shusterman, W. J. Elliott, and W. B. White, “Fenoldopam, but not nitroprusside, improves renal function in severely hypertensive patients with impaired renal function,” The American Journal of Medicine, vol. 95, no. 2, pp. 161–168, 1993.
P. Lund-Johansen and P. Omvik, “Prizidilol in essential hypertension: long-term effects on plasma volume, extracellular fluid volume, and central hemodynamics at rest and during exercise,” Journal of Cardiovascular Pharmacology, vol. 4, no. 6, pp. 1012–1017, 1982.
S. G. Raja and N. Fida, “Should angiotensin converting enzyme inhibitors/angiotensin II receptor antagonists be omitted before cardiac surgery to avoid postoperative vasodilation?” Interactive Cardiovascular and Thoracic Surgery, vol. 7, no. 3, pp. 470–475, 2008.
A. Khoynezhad, R. Bello, D. R. Smego, L. Nwakanma, and K. A. Plestis, “Improved outcome after repair of descending and thoracoabdominal aortic aneurysms using modern adjuncts,” Interactive Cardiovascular and Thoracic Surgery, vol. 4, no. 6, pp. 574–576, 2005.
F. Jafarzadeh, M. L. Field, D. K. Harrington et al., “Novel application of acetazolamide to reduce cerebrospinal fluid production in patients undergoing thoracoabdominal aortic surgery,” Interactive Cardiovascular and Thoracic Surgery, vol. 18, no. 1, pp. 21–26, 2014.
H. J. Safi, M. P. Campbell, C. C. Miller III et al., “Cerebral spinal fluid drainage and distal aortic perfusion decrease the incidence of neurological deficit: the results of 343 descending and thoracoabdominal aortic aneurysm repairs,” European Journal of Vascular and Endovascular Surgery, vol. 14, no. 2, pp. 118–124, 1997.