Long-Term Results of Endovascular Repair for Descending Thoracic Aortic Aneurysms

Abstract

Since thoracic endovascular aortic repair (TEVAR) received US Food and Drug Administration approval for the treatment of descending thoracic aneurysms in March 2005, excellent 30-day and midterm outcomes have been described. However, data on long-term outcomes is lacking with Medicare data suggesting that TEVAR has worse late survival compared with open descending repair. As such, the purpose of this study was to examine the long-term outcomes for on-label use of TEVAR for repair of descending thoracic aneurysm. Of 444 patients undergoing TEVAR between March 2005 and April 2016 at a single referral center for aortic surgery, 200 (45.0%) were performed for a descending thoracic aneurysm indication including 113 fusiform (56.5%), 81 saccular (40.5%), and six both saccular and fusiform (3.0%). All aneurysms were located distal to the left common carotid artery and proximal to the celiac axis, and hybrid procedures including arch or visceral debranching were excluded with the exception of left carotid-subclavian artery bypass. Aortic dissection and intramural hematoma as indications for TEVAR were also excluded. Primary 30-day/in-hospital outcomes included mortality, stroke, need for new permanent dialysis, and permanent paraparesis/paraplegia. Primary long-term outcomes included survival and rate of reintervention secondary to endoleak. The Kaplan- Meier method was used to estimate long-term overall and aorta-specific survival. Mean age was 71.0 ± 10.5 years (Table). All aneurysms were degenerative in nature with no patients with a connective tissue disorder. Mean aortic diameter was 5.8 ± 1.5 cm at time of intervention. Thirty-day rates of in-hospital mortality, stroke, permanent dialysis, and permanent paraparesis/paraplegia were 4.5%, 2.0%, 0.5%, and 1.0%, respectively. At a mean follow-up of 35 ± 32 months (range, 1-156 months), there were 61 late deaths (30.5%), two of which were due to aortic rupture. Actuarial overall and aorta-specific 13-year survival were 43.3% and 95.7%, respectively (Fig). Endovascular reintervention was required in 14 patients (6.9%) because of type I (n = 10), type II (n = 2), and type III (n = 2) endoleak, all of which subsequently resolved. Zero patients required open reintervention for any cause. Long-term (13-year) aorta-specific survival following endovascular repair of degenerative descending thoracic aneurysms in nonsyndromic patients is excellent (96%) with a low rate of reintervention due to endoleak (7%), and endovascular repair should be considered the treatment of choice for this pathology.TablePatient and procedural characteristicsDemographicsTotal (N = 200) Age, years71.0 ± 10.5 Male sex55.5% (111) White race72.5% (145) BMI27.9 ± 5.6 ComorbiditiesHypertension91.0% (182)Hyperlipidemia73.5% (147)History of tobacco use68.0% (136)Diabetes mellitus21.0% (42)Coronary artery disease38.0% (76)Congestive heart failure4.0% (8)History of stroke11.0% (22)PAD33.5% (67)COPD33.5% (67)CKD20.5% (41)Connective tissue disorder0.0% (0)Prior aortic surgery40.0% (80)ASA score, median3 (2-4)Case status Elective75.0% (150) Urgent/emergent25.0% (50)Indication for TEVAR DTA, fusiform56.5% (113) DTA, saccular40.5% (81) DTA, fusiform and saccular3.0% (6)Endovascular devices Gore TAG/C-TAG56.0% (112) Medtronic Talent16.0% (32) Cook Zenith10.5% (21) Medtronic Valiant10.0% (20) Cook TX2LP/Alpha Thoracic8.0% (16) Bolton Relay1.5% (3) Medtronic Aneurx0.5% (1)30-day/in-hospital outcomes Mortality4.5% (9) Stroke2.0% (4) New permanent dialysis0.5% (1) Permanent paraparesis/paraplegia0.5% (1)ASA, American Society of Anesthesiologists; BMI, body mass index; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; DTA, descending thoracic aneurysm; TEVAR, thoracic endovascular aortic repair. Open table in a new tab