Outcomes of Endovascular Repair of Ruptured Descending Thoracic Aortic Aneurysms

Abstract

Conclusions: Endovascular repair of ruptured descending thoracic aortic aneurysms (TAAs) provides encouraging results but is associated with a significant rate of neurologic complications and a relatively high rate of endoleak. Summary: Ruptured TAAs are relatively rare with reported an incidence of only about 5 per 100,000. Mortality is high and is thought to exceed 90% (Johannson G. J Vasc Surg 1995;21:985-8). There is little information on endovascular treatment of ruptured TAAs. Ruptures of true degenerative TAAs are often lumped in other series combining penetrating aortic ulcers, thoracic aortic trauma and complications of type B dissection. The authors accumulated a “pure” series of ruptured descending TAAs by identifying patients treated with endovascular repair for ruptured AA at 7 different centers between July 2002 and July 2009. There were 87 patients in this retrospective study with a mean age of 69.8 ± 12 years and 69.0% were men. At presentation 40.2% were hemodynamically unstable and 21.8% were in hypovolemic shock. Following endovascular repair mortality was 18.4%. Increased 30-day mortality after adjusting for age, was associated with hypovolemic shock (OR, 4.75; 95% CI, 1.37 to 16.5; P = .014) and hemothorax on admission (OR, 6.65; 95% CI, 1.64 to 27.1; P = .008). Ruptured TAA s were successfully excluded during TEVAR in 95.4%. Stroke occurred in 8% (n = 7). Four patients died of stroke. Post operative paraplegia occurred in 8% (n = 7) and was permanent in 2 patients and transient in 5. There was an 18.4% incidence of endoleak during the first 30 days (n = 16) with type 1 of endoleaks occurring in 10 patients, type 2 endoleaks in 5 patients and a type 3 endoleak in one patient. There were 2 late aortic esophageal fistulas that were fatal. Estimated freedom from aneurysm related death or intervention was 54.9% at 4 years. Comment: Short term mortality rates of TEVAR treatment of descending TAA rupture compares favorably with open repair of descending TAA rupture (Schermerhorn ML, et al. J Vasc Surg 2008;48:821-7). Endovascular repair of a descending ruptured TAA does appear to be associated with a high rate of neurologic and procedurally related complications, particularly type 1 endoleak. The data make it reasonably to consider TEVAR for repair of a ruptured descending TAA but morbidity and mortality are still significant.