LATE OUTCOMES OF PATIENTS WITH THORACIC ENDOVASCULAR AORTIC REPAIR (TEVAR) IN A LARGE SINGLE CENTER COHORT: ARE WE DOING THE RIGHT THERAPY?

Abstract

Since its introduction, thoracic endovascular aortic repair (TEVAR) has gained widespread acceptance for treatment of thoracic aortic diseases. While early benefits in terms of mortality and morbidity are well documented, reports of late outcomes after TEVAR are limited. We herein report the late outcomes of a large cohort of patients treated with TEVAR in a single large institution. Since 2001, 330 patients were treated by TEVAR; 6,4% (21/330) died perioperatively. All 309 surviving patients were followed prospectively by chest tomography (CT) in a dedicated thoracic aortic clinic; mean FU 5.2± 4.0 years, mean CT/pt: 5.4± 2.9. At operation, mean age was 63.0± 15.6; 76.3% male. Operative indication was: aneurysm 43.4%, dissection 17.5%, complicated penetrating ulcer /intramural hematoma 18.1%, traumatic rupture 14.2%, other indications in 6.2%; 36.6% of procedures were emergent. Proximal landing zone was in zone 0-1 in 22,6% of cases, zone 2 in 34,3% and zone 3 in 43.1%. Late death occurred in 79 pts; with five year overall survival, five-year freedom from aortic and TEVAR related deaths of respectively 78.5%, 98.3% and 93.3%. Predictors of late deaths by multivariate analysis were: COPD OR: 3.46 (1.25-9.59) p=0.02, age OR 1.1 (1.04-1.11) p<0.0001 and TEVAR infection: OR: 23.66 (2.56-218.86) p=0.005. Forty-four patients presented a type I endoleak at a mean of 2.2± 2.9 years after TEVAR implant; five-year freedom of type I endoleak of 74.3%. Type I endoleak was significantly increased in patients with dissection mainly owing to distal septal perforation. An aorto-bronchial or esophageal perforation was observed in 7 patients (2.3%) at a mean of 2.7± 2.3 years (mortality rate 57,1%); while a TEVAR infection was diagnosed in 9 patients (2.9%) at a mean of 1.2 ± 1.6 years (mortality rate 77.8%). Freedom from reintervention (open surgery or redo-TEVAR) was 83.9% at 5-years. Overall survival of TEVAR is good with acceptable TEVAR related deaths mainly owing too infectious and fistula complications. Late complications such as endoleak, infection and fistula mandate rigorous clinical and imaging follow-up for early detection and prompt reintervention in good risk patients.