Invited Commentary

Abstract

Thoracic endovascular approaches are rapidly gaining favor for treating descending thoracic aortic pathology. Dick and colleagues [1Dick F. Hinder D. Immer F.F. et al.Outcome and quality of life after surgical and endovascular treatment of descending aortic lesions.Ann Thorac Surg. 2008; 85: 1605-1613Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar] present a comparative assessment of the quality of life after open aortic repair (OAR) and thoracic endovascular aortic repair (TEVAR) of descending and thoracoabdominal aortic pathology. With the recent Food and Drug Administration's sponsored multicenter trials suggesting either improved or equivalent early outcomes, this analysis is timely and brings a very important question to the forefront for those of us practicing aortic surgery in 2008 [2Bavaria J.E. Appoo J.J. Makaroun M.S. et al.Endovascular stent-grafting versus open surgical repair of descending thoracic aortic aneurysms in low risk patients: a multicenter comparative trial.J Thorac Cardiovasc Surg. 2007; 133: 369-377Abstract Full Text Full Text PDF PubMed Scopus (417) Google Scholar, 3Matsumura J.S. Cambria R.P. Dake M.D. et al.International controlled clinical trial of thoracic endovascular aneurysm repair with the Zenith TX2 endovascular graft: 1 year results.J Vasc Surg. 2008; 47: 247-257Abstract Full Text Full Text PDF PubMed Scopus (275) Google Scholar]. On one hand, we have OAR, which has a long track record of success, but carries with it a significant rate of morbidity and associated need for a long period of convalescence. In contrast, TEVAR has emerged as a potential alternative to reduce early morbidity and shorten both hospitalization and recovery times, but has uncertain late results. Which is a more appropriate option? To completely answer this question, not only does the efficacy of the therapy need to be better defined, but also the impact of these options in patients who are often asymptomatic. Although many previous reports have documented outcomes for OAR and TEVAR, this study is one of the first to assess data obtained from quality-of-life (QoL) questionnaires long after either open or endovascular aortic repair. The entry criteria for this study, as detailed in the methods section, suggest a significant selection bias favoring entry into the TEVAR arm for (1) patients older than 65 years of age, (2) patients presenting in emergent situations, and (3) patients with disease confined to the thorax. The QoL questionnaires were obtained from 78% of those surviving the operative procedure at a mean of 29 months for TEVAR and 37 months for OAR. Because there were significant baseline differences in age and presentation between the groups, the results from QoL questionnaires were compared with age and the sex-adjusted standard population, rather than to each other. The results suggest that those undergoing TEVAR had a surprisingly lower score in overall physical health and QoL when compared with a validated Swedish standard population. In contrast, the OAR group scores were all within normal ranges seen for the standard population, prompting the authors to suggest that the advantages of a minimally invasive approach may not affect the long-term quality of life. There are some very important points that should be noted prior to agreeing with this conclusion. First, the rates of major morbidity, including stroke (7% to 10%), paraplegia (3% to 4%), renal insufficiency (10% to 14%), or need for tracheostomy (7% to 8%), were not significantly different between the groups. Differences in frequency of these postoperative complications would likely affect long-term quality of life, both physically and mentally. Second, the rates of aortic causes of death were higher in the TEVAR versus the open repair group, and may relate to the observed 21% endoleak rate. Third, although there were some differences in both overall physical health and QoL scores for the TEVAR group, this was not statistically different between groups. Finally, and most importantly, the questionnaires were obtained from a single point in the time period of recovery. In particular, there is no preoperative or early postoperative assessment of QoL. Because recovery is a continual process, these missing data are of particular concern. Although the authors are to be congratulated for their attempts to shed light on this very important topic, we await further studies in similar groups of patients with more longitudinal data to help answer the question, “Which is the more appropriate therapeutic option?” Outcome and Quality of Life After Surgical and Endovascular Treatment of Descending Aortic LesionsThe Annals of Thoracic SurgeryVol. 85Issue 5PreviewThoracic endovascular aortic repair (TEVAR) represents an attractive alternative to open aortic repair (OAR). The aim of this study was to assess outcome and quality of life in patients treated either by TEVAR or OAR for diseased descending thoracic aorta. Full-Text PDF