Outcome and Quality of Life After Surgical and Endovascular Treatment of Descending Aortic Lesions

Abstract

Conclusion: Long-term quality of life (QOL) is reduced after thoracic aortic repair. Thoracic endovascular aneurysm repair (TEVAR) patients do not score higher in QOL compared with open repair patients. Summary: Health-related QOL is now regarded as an important variable in the evaluation of any invasive treatment. A small series of QOL assessments after open aortic repair (OAR) for thoracic aortic pathologies have found that QOL is impaired after OAR. Studies focusing on abdominal aortic aneurysm repair have found the QOL is still impaired after endovascular repair of abdominal aortic aneurysms. Similar data are lacking in patients treated with TEVAR. The aim of this single-center series was to assess outcome and postoperative long-term QOL in patients treated for a variety of thoracic aortic pathologies by OAR or TEVAR. The results were compared with standard populations adjusted for age and sex. The study is essentially a post hoc analysis of a prospectively maintained database. Between January 2001 and December 2005, 136 patients with a surgical problem of the descending thoracic aorta were treated at the authors' institution. Excluded from further analyses were 14 patients because of concurrent involvement of the ascending aorta. Fifty-two patients underwent TEVAR and 70 underwent OAR. Mean follow-up was 34 ± 18 months. End points were perioperative and late mortality and long-term QOL. QOL was assessed by the Short Form 36-Item Health Survey (SF-36) and the Hospital Anxiety and Depression Score questionnaires. TEVAR patients were older than the OAR patients (69 ± 10 vs 62 ± 15 years; P = .002). Operative mortality did not differ between patients treated with OAR (9%) and TEVAR (8%; P = .254), and long-term mortality was similar. Overall QOL scores were 93 (range, 63-110) for OAR and 83 (range, 60-112) for TEVAR. The QOL scores adjusted for age and sex in a healthy population range from 85 to 115. Comment: The results of this study are a bit surprising. However, the patients were not randomized and the demographics of the TEVAR vs OAR groups suggest a selection bias favoring entry into the TEVAR arm for patients aged >65 years and for those with disease confined to the thorax and those presenting with an emergency situation. These differences in the baseline characteristics of the patients led the authors to compare their QOL results with an age- and sex-adjusted standard population rather than to compare the OAR patients directly with the TEVAR patients. Another selection bias may result because patients with higher levels of pre-existing depression and anxiety may be offered the less invasive procedure. Surprisingly, QOL scores in the OAR patients were within the normal range. Those of the TEVAR were lower compared with the normalized population. The findings parallel those of the Dutch Randomised Endovascular Aneurysm Management (DREAM) trial, which also found poor long-term QOL after EVAR for abdominal aortic aneurysm (N Engl J Med 2005;352:2398-405). One thing is becoming increasingly clear: underlying comorbidities in patients with thoracic aortic disease make it rare to truly hit a “home run” in patients with thoracic aortic pathology, irrespective of what therapy is used.