Endovascular treatment of descending thoracic aortic disease: single-center, 15-year experience

Long-term Thoracic Endovascular Repair follow-up from 1999-2019 - a Single-Center Experience

INTRODUCTION

Thoracic endovascular aortic repair (TEVAR) was introduced in the early 1990's, and long-term follow-up studies are warranted in current guidelines.

METHODS

Patients undergoing TEVAR were consecutively included from 1999-2019. Thoracic aortic disease includes thoracic aortic aneurysms, aortic dissection, traumatic rupture, penetrating aortic ulcer (PAU) and intramural hematoma (IMH). Our prospective database recorded baseline characteristics, endoleak or aneurysm growth and death. Patients were included at time of treatment and censored at death, or first reintervention depending on the analysis. Primary endpoint was all-cause death, secondary endpoint was reintervention. Survival and failure analysis were done using StataIC 16.0® and truncated at 15 years of follow-up.

RESULTS

256 patients were included - 63% were men. Their mean age at intervention was 66.2 ± 14.5 years and they were followed for a mean of 5.2 ± 4.5 years. Indications for TEVAR were acute aortic syndrome 40.6%, chronic aortic disease 44.5%, and traumatic rupture in 14.8 %. Technical success was seen in 94.1 % of the operations, and the left subclavian artery was covered in 27.7%. 30-day mortality rate was 21.2% (22/104) and 1.75% (2/114) (p<0.001) for urgent and elective patients, respectively. Twelve patients (4.7%) died within 24 hours of treatment. Overall, long-term mortality recorded112 (43,8%) deaths, 29 patients had reinterventions (11.3 % (95% confidence interval: 7.7-15.9)), aneurysms accounted for 62.1% of all reinterventions. 24 (82.8%) reinterventions occurred within the first 5 years.

CONCLUSION

This long-term follow-up study shows excess mortality in patients treated for acute aortic syndrome compared to chronic aortic disease, within the first 30 days, this difference diminishes at the end of follow-up. Most endoleak occur within the first five years, though new endoleak continue to develop decades after in previous endoleak-free patients calling for lifelong surveillance.

Clinical outcomes of endovascular treatment for ruptured thoracic aortic disease

BACKGROUND/AIMS

Untreated rupture of the thoracic aorta is associated with a high mortality rate. We aimed to review the clinical results of endovascular treatment for ruptured thoracic aortic disease.

METHODS

We retrospectively reviewed data on 37 patients (mean age, 67.0 ± 15.18 years) treated for ruptured thoracic aortic disease from January 2005 to May 2016. The median follow-up duration was 308 days (interquartile range, 61 to 1,036.5). The primary end-point of the study was the composite of death, secondary intervention, endoleak, and major stroke/paraplegia after endovascular treatment.

RESULTS

The etiologies of ruptured thoracic aortic disease were aortic dissection (n = 11, 29.7%), intramural hematoma (n = 7, 18.9%), thoracic aortic aneurysm (n = 14, 37.8%), and traumatic aortic transection (n = 5, 13.5%). Three patients died within 24 hours of thoracic endovascular aortic repair, and one showed type I endoleak. The technical success rate was 89.2% (33/37). The in-hospital mortality rate was 13.5% (5/37); no deaths occurred during follow-up. The composite outcome rate during follow-up was 37.8% (14/37), comprising death (n = 5, 13.5%), secondary intervention (n = 5, 13.5%), endoleak (n = 5, 13.5%), and major stroke/paraplegia (n = 3, 8.1%). Left subclavian artery revascularization and proximal landing zone were not associated with the composite outcome. Low mean arterial pressure (MAP; ≤ 60 mmHg, [hazard ratio, 13.018; 95% confidence interval, 2.435 to 69.583, p = 0.003]) was the most significant predictor and high transfusion requirement in the first 24 hours was associated with event-free survival (log rank p = 0.018).

CONCLUSION

Endovascular treatment achieves high technical success rates and acceptable clinical outcome. High transfusion volume and low MAP were associated with poor clinical outcomes.

Respiratory Failure after Open Descending Aortic Aneurysm Repair: Risk Factors and Outcomes

Purpose: This study was conducted to identify predictors of respiratory failure after open repair of descending thoracic aortic aneurysm (DTAA), and to identify any relationship between respiratory failure and long-term survival.

Methods: A total of 75 patients undergoing elective open DTAA repair at the Shiga University of Medical Science Hospital were included in the study. Univariate and multivariate logistic regression analyses were performed to assess the odds ratios for incident postoperative respiratory failure after open DTAA repair. Survival over time was estimated by the Kaplan–Meier method.

Results: Respiratory failure, defined as ventilation dependence for longer than 48 hours, occurred in 11 patients (14.7%). Independent predictors of respiratory failure after DTAA included prolonged operation time and reduced preoperative forced expiratory volume in 1 second/forced vital capacity × 100 (FEV₁%). In-hospital mortality was higher (p = 0.020) among patients with respiratory failure (18.2% of those who suffered respiratory failure) than among those without (0%). The survival rates at 8 years were significantly lower (p = 0.010) in the respiratory failure group (at 44.2%) than in the group without respiratory failure (at 89.0%).

Conclusion: Lower FEV₁% and longer operation time were risk factors of postoperative respiratory failure after open repair of DTAA, which in turn is associated with significantly reduced long-term survival.

Overall survival and factors predicting long-term outcome after thoracic aortic endovascular repair

PURPOSES

To assess overall survival and to determine factors predicting outcome after thoracic endovascular aortic repair.

MATERIALS AND METHODS

A Retrospective analysis was performed on a cohort of 212 consecutive patients (165 men and 47 women; mean age 64 years) who underwent thoracic endovascular aortic repair in a tertiary referral center for aortic disease. Main indications were true thoracic aortic aneurysm (n = 58; 27.6%), traumatic aortic rupture (n = 33; 15.7%), anastomotic pseudoaneurysms (n = 23; 10.9%), chronic type B aortic dissection (n = 22; 10.5%), and symptomatic, acute type B dissection (n = 21; 10.0%). In 79 patients (37.3%), a hybrid procedure, including supra-aortic rerouting, was performed. Kaplan-Meier estimates were used for overall survival and Cox regression models were used for univariable analysis of the association between risk factors and survival.

RESULTS

Proximal landing zones were predominantly zone 3 (n = 66; 31.3%), zone 2 (n = 63; 29.9%), and zone 1 (n = 38; 18%). In-hospital mortality was n = 18 (8.5%). Overall survival was 79.6%, 65.9%, and 51.1% at 2, 5, and 10 years, respectively; better overall survival was shown for traumatic aortic rupture, anastomotic pseudoaneurysms, and chronic posttraumatic pseudoaneurysms (p < 0.05). Clinical risk factors influencing overall survival include prior coronary bypass surgery, atrial flutter, arterial hypertension, renal failure, chronic obstructive pulmonary disease, and associated abdominal aortic aneurysm (p < 0.05).

CONCLUSIONS

Thoracic endovascular aortic repair is an effective treatment option for various thoracic aortic diseases with highest survival rates for traumatic aortic rupture and anastomotic pseudoaneurysms. Several clinical parameters are identified as risk factors for overall survival.

Endovascular management of penetrating and non-penetrating aortic injury

Aortic trauma is a devastating injury often associated with significant polytrauma. Penetrating injury of the aorta is highly lethal and therefore rarely encountered in the hospital setting. The management of blunt trauma of the aorta has changed significantly over the past decade, principally due to improved imaging technology and the development of endovascular therapy. The most common site of injury is the proximal descending thoracic aorta. The degree of aortic wall injury guides the indication for therapy, while a combination of the degree of injury and the extent of co-morbid injuries drives the timing of repair. Lower grade injuries frequently do not require any surgical intervention. Thoracic aortic endograft repair can be performed in a safe, expeditious fashion. Short-term and mid-term outcomes appear excellent, with patient survival based mainly on concomitant traumatic injuries. Long-term outcomes are less well known. Future endeavors will be guided toward gaining a better understanding of the indications for repair and the long-term outcomes for endograft devices designed for this purpose.