Thoracic Endovascular Aortic Repair for Metachronous Thoracic Aortic Aneurysms Following Prior Infrarenal Abdominal Aortic Aneurysm Repair

Abstract

Thoracic endovascular aortic repair (TEVAR) for metachronous thoracic aortic aneurysms (M-TAA) after prior abdominal aortic aneurysm repair has been shown to be associated with higher risk of spinal cord ischemia compared with primary TEVAR. However, data regarding the impact of the type of prior repair on outcomes are scarce. In this study, we examined perioperative outcomes and long-term mortality after TEVAR for M-TAA compared with primary TEVAR for TAA. We identified all patients who underwent TEVAR for TAA of the descending thoracic aorta in the Vascular Quality Initiative from 2013 to 2022. Only patients undergoing primary TEVAR or TEVAR after infrarenal open (iOAR) or endovascular (EVAR) repair were included. We performed univariate analyses to identify differences in baseline and procedural characteristics, and multivariable analyses for perioperative outcomes and 5-year mortality using logistic and Cox regression models. We included 1493 patients who underwent primary TEVAR (n = 1213; 81%) or TEVAR after prior iOAR (n = 135; 9%) or prior EVAR (n = 145; 10%). Compared with primary TEVAR, patients undergoing TEVAR for metachronous aneurysms were older, more commonly male, White, and more frequently had a history of genetic disorders and other comorbidities. Patients with M-TAA were more often asymptomatic at repair, presented with larger diameters, and required higher contrast volume and longer procedural time, relative to patients undergoing primary TEVAR. After risk adjustment, compared with primary TEVAR, prior EVAR was associated with higher perioperative mortality (10% vs 3.9%; odds ratio [OR]: 4.5, 95% confidence interval [CI]: 2.0-9.9; P < .001) (Table) and 5-year mortality (40% vs 24%; hazard ratio: 1.9, 95% CI: 1.3-2; P = .001) (Fig), along with higher odds of acute kidney injury (10% vs 6.2%; OR: 2.0, 95% CI: 1.0-3.8; P = .04). However, other in-hospital complications including spinal cord ischemia were not notably different. On the other hand, TEVAR after prior iOAR was associated with similar perioperative mortality (4% vs 4%; OR: 0.8, 95% CI: 0.3-2.0; P = .75), 5-year mortality (28% vs 24%; hazard ratio: 1.2, 95% CI: 0.72-1.9; P = .54), and in-hospital complication and reintervention rates, relative to primary TEVAR. Type of prior repair has a significant impact on outcomes in patients undergoing intervention for M-TAA. Further efforts should aim to identify the reasons behind these differences in outcomes to help improve care of patients with M-TAA.TablePerioperative outcomes and 5-year mortality after primary TEVAR and TEVAR after prior iOAR or EVARPrimary TEVARPrior iOARPrior EVARPrimary TEVAR vs prior iOARPrimary TEVAR vs prior EVARUnadjusted event rates, %Odds ratio (95% CI)P valueOdds ratio (95% CI)P valuePerioperative mortality3.94.49.71.2 (0.32-3.7).754.5 (2.0-9.9)<.001Any complication1814230.92 (0.50-1.6).771.5 (0.89-2.3).13 AKI6.26.7101.3 (0.56-2.9).492.0 (1.0-3.8).04 Postoperative dialysis1.01.51.42.1 (0.24-1.2).461.4 (0.07-9.1).78 Spinal cord ischemia2.60.72.80.22 (0.01-1.2).161.3 (0.35-3.5).69 Leg ischemia1.90.72.11.2 (0.06-7.2).862.0 (0.42-7.0).33 Bowel ischemia0.501.4NANA3.0 (0.40-15).22 Stroke3.11.54.10.63 (0.10-2.3).541.3 (0.40-3.3).58 Pulmonary complication5.06.76.91.8 (0.72-4.0).181.9 (0.83-3.8).11 Cardiac complication2.53.02.81.7 (0.45-5.2).971.02 (0.23-3.2).97Reintervention4.93.76.21.2 (0.38-3.0).761.5 (0.64-3.3).30Unadjusted estimatesHazard ratio (95% CI)P valueHazard ratio (95% CI)P value5-year mortality2325401.2 (0.72-1.9).541.9 (1.3-2.8).001AKI, Acute kidney injury; CI, confidence interval; iOAR, infrarenal open aortic repair; TEVAR, thoracic endovascular aortic repair.Boldface P values represent significance P < .05.*Adjusted for age, gender, diameter, race, saccular, presentation, prior myocardial infarction, prior congestive heart failure, hypertension, diabetes, chronic obstructive pulmonary disease, smoking, renal dysfunction, prior medication use (aspirin, statin, and β-blocker), and genetic history. Open table in a new tab