National Registry Insights on Genetic Aortopathies and Thoracic Endovascular Aortic Interventions

OBJECTIVE

Thoracic endovascular aortic repair (TEVAR) in patients with genetic aortopathies (GA) is controversial given concerns of durability. We describe characteristics and outcomes following TEVAR in patients with GA.

METHODS

All patients undergoing TEVAR between 2010-2023 in the VQI were identified and categorized as having a GA or not. Demographics, baseline, and procedural characteristics were compared among groups. Multivariable logistic regression was used to evaluate the independent association of GA with postoperative outcomes. Kaplan-Meier methods and multivariable Cox-regression analyses were used to evaluate 5-year survival and 2-year reinterventions.

RESULTS

Of 19,340 patients, 304 (1.6%) had GA (87% Marfan; 9% Loeys-Dietz; and 4% Vascular Ehlers-Danlos). Compared with non-GA, GA patients were younger (50 [37-72] years vs. 70 [61-77] years), more often presented with acute dissection (28% vs. 18%), post-dissection aneurysm (48% vs. 17%), had symptomatic presentation (50% vs. 39%), and were less likely to have degenerative aneurysms (18% vs. 47%) or PAU [+ IMH] (3% vs. 13%) (all p<.001). GA patients were more likely to have prior repair of the ascending aorta/arch (open: 56% vs. 11%;p<.001; endovascular 5.6% vs. 2.1%;p=.017) or the descending thoracic aorta (open: 12% vs. 2%;p=.007; endovascular 8.2% vs. 3.6%;p=.011). No significant differences were found in prior abdominal suprarenal repairs, however, GA patients had more prior open infrarenal repairs (5.3% vs. 3.2%), but fewer prior endovascular infrarenal repairs (3.3% vs. 5.5%)(all p<.05). After adjusting for demographics, comorbidities, and disease characteristics, patients with GA had similar odds of perioperative mortality (4.6% vs. 7.0%; aOR:1.1 [95%CI: 0.57-1.9];p=.75), any in-hospital complication (26% vs. 23%; aOR:1.24 [0.92-1.6];p=.14), or in-hospital reintervention (13% vs. 8.3%; aOR:1.25 [0.84-1.8];p=.25) compared with non-GA patients. However, GA patients had higher likelihood of post-operative vasopressors (33% vs. 27%; aOR:1.44 [1.1-1.9];p=.006) and transfusion (25% vs. 23%; aOR:1.39 [1.03-1.9]; p=.006). 2-year reintervention rates were higher in GA patients (25% vs. 13%; aHR:1.99 [1.4-2.9];p<.001), but 5-year survival was similar (81% vs. 74%; aHR:1.02 [0.70-1.5];p=.1).

CONCLUSIONS

TEVAR for GA patients appeared to be initially safe with similar odds for in-hospital complications, in-hospital reinterventions, and perioperative mortality, as well as similar hazards for 5-year mortality compared with non-GA patients. However, GA patients had higher 2-year reintervention rates. Future studies should assess long-term durability after TEVAR compared with the recommended open repair to appropriately weigh risks and benefits of endovascular treatment in GA patients.

Prevalence and outcomes of select rare vascular conditions in females: A descriptive review

Rare vascular conditions frequently pose a diagnostic and therapeutic dilemma for health care providers. Several of these conditions have distinct relevance to females populations but, due to their infrequency, there has been little reported on the outcomes of rare vascular conditions specifically in females populations. We performed a literature review of a selection of three rare vascular conditions known to either disproportionately affect females (median arcuate ligament syndrome and fibromuscular dysplasia) or have unique manifestations in females populations (vascular Ehlers-Danlos syndrome). We performed a descriptive review of the literature focused on these three vascular conditions and identified aspects of the current available research describing sex-based differences in prevalence, any pathophysiology explaining the observed sex-based differences, and the contribution of sex to outcomes for each disease process. In addition, considerations for pregnant females with respect to each rare vascular disease process are discussed.

Neuroendovascular Procedures in Patients with Ehlers-Danlos Type IV: Multicenter Case Series and Systematic Review

BACKGROUND

Ehlers-Danlos type IV or vascular Ehlers-Danlos syndrome (vEDS) is a rare inherited disorder characterized by profound vascular fragility resulting from defective production of type III procollagen. Cerebrovascular diseases including spontaneous dissections, cerebral aneurysms, and cavernous carotid fistulae are common. Endovascular therapies in this patient population are known to be higher risk, although many studies (before 2000) involved older techniques and equipment. The purpose of this study is to investigate the safety and efficacy of modern neuroendovascular techniques in the treatment of cerebrovascular diseases in patients with vEDS.

METHODS

We combined a multi-institutional retrospective case series at 3 quaternary-care centers with a systematic literature review of individual case reports and case series spanning 2000-2021 to evaluate the safety and efficacy of neuroendovascular procedure in patients with vEDS with cerebrovascular diseases.

RESULTS

Fifty-nine patients who underwent 66 neuroendovascular procedures were evaluated. Most of the patients had direct cavernous carotid fistulas (DCCF). Neuroendovascular procedures had a 94% success rate, with a complication rate of 30% and a mortality of 7.5%.

CONCLUSIONS

Neuroendovascular procedures can be performed with a high rate of success in the treatment of cerebrovascular diseases in patients with vEDS, although special care is required because complication rates and mortality are high. Access site and procedure-related vascular injuries remain a significant hurdle in treating vEDS with cerebrovascular diseases, even with modern techniques.