A Frailty-Based Risk Score Predicts Morbidity and Mortality After Elective Endovascular Thoracic Aortic Aneurysm Repair

Previous thoracic aortic repair is not associated with adverse outcomes after thoracic endovascular aortic repair

BACKGROUND

As many as 20% of patients who have undergone previous thoracic aortic repair will require reintervention, which could entail thoracic endovascular aortic repair (TEVAR). A paucity of data is available on mortality and the incidence of spinal cord ischemia (SCI) and other postoperative complications associated with TEVAR after previous aortic repairs exclusive to the thoracic aorta. The aim of the present study was to assess the effect of previous thoracic aortic repair on the 30-day mortality and SCI outcomes for patients after TEVAR.

METHODS

The Society for Vascular Surgery Vascular Quality Initiative database was queried for all cases of TEVAR from 2012 to 2018. Patients were excluded if they had undergone previous abdominal aortic repair, the TEVAR had extended beyond aortic zone 5, or SCI data were missing. The 3 cohorts compared were TEVAR with previous ascending aortic or aortic arch repair (group 1), TEVAR with previous descending thoracic aortic repair (group 2), and TEVAR without previous repair (group 3). The primary outcomes of interest were 30-day mortality and SCI. The secondary outcomes included stroke, myocardial infarction, cardiac complications, respiratory complications, postoperative length of stay, and reintervention. The patient variables were compared using χ2 tests, analysis of variance, or Kruskal-Wallis tests, as appropriate. Logistic regression analysis was performed to identify the predictors of 30-day mortality and SCI.

RESULTS

A total of 4010 patients met the inclusion criteria, with 470 in group 1, 132 in group 2, and 3408 in group 3. The 30-day mortality was 4% (19 of 470) in group 1, 6% (8 of 132) in group 2, and 6% (213 of 3408) in group 3 (P = .17). The incidence of SCI was 3% (14 of 470) in group 1, 3% (4 of 132) in group 2, and 3.8% (128 of 3408) in group 3 (P = .65). Stroke, reintervention, myocardial infarction, and cardiac complications were not significantly different among the 3 groups. The incidence of respiratory complications was greatest for group 3 (11%; 360 of 3408) compared with groups 1 (9%; 44 of 470) and 2 (4%; 5 of 132; P = .034). Similarly, the postoperative length of stay was longest for group 3 (9.6 ± 19.4 days vs 8.2 ± 18.3 days for group 1 and 5.9 ± 8.6 days for group 2; P = .038). The independent predictors of 30-day mortality for all TEVAR patients included units of packed red blood cells transfused intraoperatively, urgent or emergent repairs, older age, increasing serum creatinine level, inability to perform self-care, total procedure time, occlusion of the left subclavian artery intraoperatively, distal endograft landing zone 5, and diabetes. The predictors of SCI included the total procedure time, urgent and emergent repairs, and increasing serum creatinine level.

CONCLUSIONS

TEVAR after previous thoracic aortic repair was not associated with an increased risk of SCI or 30-day mortality compared with TEVAR without previous aortic repair.

CT-Derived Pretreatment Thoracic Sarcopenia Is Associated with Late Mortality after Thoracic Endovascular Aortic Repair

BACKGROUND

Frailty, characterized by physiologic depletion, predicts postoperative morbidity and mortality in vascular surgery patients. CT-derived sarcopenia is a valuable method for objectively staging frailty preoperatively.

PURPOSE

With prior analyses primarily measuring psoas cross-sectional area on CT, we compared a method of measuring thoracic sarcopenia to existing techniques of lumbar sarcopenia and assessed the association with long-term survival and outcomes post-Thoracic Endovascular Aortic Repair (TEVAR).

METHODS

Prospectively collected data of 217 patients undergoing TEVAR from 2009 to 2012 were reviewed. Thoracic sarcopenia was quantified by measuring total area of the rectus abdominis, latissimus dorsi, intercostal, erector spinae, and external and internal oblique muscles at the T12 vertebral level. Total psoas area at the L3 was used to measure lumbar sarcopenia.

RESULTS

200 patients had preoperative imaging enabling measurements of thoracic sarcopenia, 186 of these patients were also assessed for lumbar sarcopenia. Thoracic sarcopenic patients were older, had lower body mass indices, were more commonly female, and most commonly being treated for aneurysms. Thoracic sarcopenic patients had significantly higher rates of congestive heart failure, hypertension, prior vascular intervention, and TEVAR-related adverse events. Thoracic sarcopenia was associated with significantly higher mortality at 2 and 5 years post-TEVAR (2-year mortality: 19% vs 8%, P = 0.02; 5-year mortality: 31% vs 18%, P = 0.03). Lumbar sarcopenia was not associated with increased mortality at any time point. Patients whose muscle mass degraded over 48-month follow-up did not experience significantly higher rates of adverse events.

CONCLUSIONS

CT-derived thoracic sarcopenia, but not lumbar sarcopenia, is significantly associated with 5-year mortality post-TEVAR.