Cohort-Comparison of Thoracic Endovascular Aortic Repair with Open Thoracic Aortic Repair Using Modern End-Organ Preservation Strategies

Abstract

Pivotal trials showed that thoracic endovascular aortic repair (TEVAR) has improved outcomes compared with open surgery for treating descending thoracic aortic aneurysms. However, those trials included historical open controls in which modern end-organ preservation strategies were not routinely employed. In an effort to create a more level assessment, we compared our outcomes of TEVAR with modern open thoracic aortic repair (OTAR) controls. A retrospective review of a prospective database of thoracic aortic aneurysm patients undergoing TEVAR was compared with a contemporaneous cohort of OTAR patients. Partial bypass or hypothermic circulatory arrest (HCA) was used in all OTAR patients. Both groups underwent cerebrospinal fluid (CSF) drain placement when feasible. Preoperative characteristics, operative variables, and outcomes were recorded, and the Kaplan-Meier method was used for 1-year survival estimates. Subgroup analysis was performed using length of aortic stent graft coverage or length of aortic replacement. During the study period (2002-2013), 81 patients underwent TEVAR and 61 underwent OTAR with median follow-up of 23.7 months (interquartile range, 6.7-55.1) and 36.4 months (interquartile range, 9.6-60.2), respectively. TEVAR patients had significantly lower 30-day mortality (2.5% vs 13.1%; P = .02) and fewer complications including pneumonia (P = .01) and rebleeding (P = .03). However, there was no difference in permanent spinal cord ischemia (SCI) (1% vs 2%; P = .9) or estimated 1-year survival (P = .9). Among OTAR patients, HCA tended to have higher 30-day mortality (16% vs 7%, P = .43). Cox regression revealed that advanced age and higher baseline creatinine levels were associated with greater hazard of 1-year mortality; TEVAR and CSF drain placement were protective of 1-year survival. For patients with <20 cm of aortic stent graft or aortic graft replacement, there was no difference in 30-day mortality (P = .07) or permanent SCI (TEVAR n = 0, 0% vs OTAR n = 1, 2%; P = .9). For those with ≥20 cm of aortic stent graft or replacement, there was no difference in 30-day mortality (P = .9) or permanent SCI (TEVAR n = 1, 2% vs OTAR n = 0, 0%; P = .9). TEVAR continues to show improved perioperative outcomes with decreased 30-day mortality and fewer major adverse events compared with OTAR. However, with the advent of routine end-organ preservation during OTAR, SCI can be safely reduced to comparable levels with those of TEVAR. Length of aortic stent graft coverage or length of surgical graft replacement does not significantly impact outcomes.