Elective Thoracic Endovascular Aortic Repair Research Articles

The impact of urgency of repair on outcomes following thoracic endovascular aortic repair for blunt thoracic aortic injury

ObjectiveCurrent societal recommendations regarding the timing of thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) vary. Prior studies have shown that elective repair was associated with lower mortality after TEVAR for BTAI. However, these studies lacked data such as Society for Vascular Surgery (SVS) aortic injury grades and TEVAR-related postoperative outcomes. Therefore, we used the Vascular Quality Initiative registry, which includes relevant anatomic and outcome data, to examine the outcomes following urgent/emergent (≤ 24 hours) vs elective TEVAR for BTAI. MethodsPatients undergoing TEVAR for BTAI between 2013 and 2022 were included, excluding those with SVS grade 4 aortic injuries. We included covariates such as age, sex, race, transfer status, body mass index, preoperative hemoglobin, comorbidities, medication use, SVS aortic injury grade, coexisting injuries, Glasgow Coma Scale, and prior aortic surgery in a regression model to compute propensity scores for assignment to urgent/emergent or elective TEVAR. Perioperative outcomes and 5-year mortality were evaluated using inverse probability-weighted logistic regression and Cox regression, also adjusting for left subclavian artery revascularization/occlusion and annual center and physician volumes. ResultsOf 1016 patients, 102 (10%) underwent elective TEVAR. Patients who underwent elective repair were more likely to undergo revascularization of the left subclavian artery (31% vs 7.5%; P < .001) and receive intraoperative heparin (94% vs 82%; P = .002). After inverse probability weighting, there was no association between TEVAR timing and perioperative mortality (elective vs urgent/emergent: 3.9% vs 6.6%; odds ratio [OR], 1.1; 95% confidence interval [CI], 0.27-4.7; P = .90) and 5-year mortality (5.8% vs 12%; hazard ratio [HR], 0.95; 95% CI, 0.21-4.3; P > .9).Compared with urgent/emergent TEVAR, elective repair was associated with lower postoperative stroke (1.0% vs 2.1%; adjusted OR [aOR], 0.12; 95% CI, 0.02-0.94; P = .044), even after adjusting for intraoperative heparin use (aOR, 0.12; 95% CI, 0.02-0.92; P = .042). Elective TEVAR was also associated with lower odds of failure of extubation immediately after surgery (39% vs 65%; aOR, 0.18; 95% CI, 0.09-0.35; P < .001) and postoperative pneumonia (4.9% vs 11%; aOR, 0.34; 95% CI, 0.13-0.91; P = .031), but comparable odds of any postoperative complication as a composite outcome and reintervention during index admission. ConclusionsPatients with BTAI who underwent elective TEVAR were more likely to receive intraoperative heparin. Perioperative mortality and 5-year mortality rates were similar between the elective and emergent/urgent TEVAR groups. Postoperatively, elective TEVAR was associated with lower ischemic stroke, pulmonary complications, and prolonged hospitalization. Future modifications in society guidelines should incorporate the current evidence supporting the use of elective TEVAR for BTAI. The optimal timing of TEVAR in patients with BTAI and the factors determining it should be the subject of future study to facilitate personalized decision-making.

Comparative Analysis of Morbidity and Mortality Outcomes in Elderly and Nonelderly Patients Undergoing Elective TEVAR: A Systematic Review and Meta-Analysis.

Due to an ever-increasing ageing population and limited available data around the use of thoracic endovascular aortic repair (TEVAR) in elderly patients, investigating its efficacy and safety in this age cohort is of vital importance. We thus reviewed the existing literature on this topic to assess the feasibility of TEVAR in elderly patients with severe thoracic aortic pathologies. We identified all original research studies that assessed TEVAR in elderly patients published up to 2023. Morbidity, as assessed by neurological and respiratory complications, endoleaks, and length of stay, was the primary endpoint. Short-term mortality and long-term survival were the secondary endpoints. The Mantel-Haenszel random and fixed effects methods were used to calculate the odds ratios for each outcome. Further sensitivity and subgroup analyses were performed to validate the outcomes. Twelve original studies that evaluated elective TEVAR outcomes in elderly patients were identified. Seven studies directly compared the use of TEVAR between an older and a younger patient group. Apart from a shorter hospital stay in older patients, no statistically significant difference between the morbidity outcomes of the two different cohorts was found. Short-term mortality and long-term survival results favoured the younger population. The present meta-analysis indicates that, due to a safe perioperative morbidity profile, TEVAR should not be contraindicated in patients based purely on old age. Further research using large patient registries to validate our findings in elderly patients with specific aortic pathologies and both elective and emergency procedures is necessary.

Open Versus Endovascular Left Subclavian Artery Revascularization Outcomes in Thoracic Endovascular Aortic Repair: A National Study

Left subclavian artery (LSA) revascularization is recommended in patients undergoing elective thoracic endovascular aortic repair (TEVAR) with LSA coverage. However, the outcomes of open vs endovascular techniques for LSA revascularization remain poorly studied due to lack of high-quality evidence. The aim of this study is to use a large national database to compare the effects of open vs endovascular LSA revascularization for LSA coverage during TEVAR on the perioperative outcomes of stroke, arm ischemia (AI), spinal cord ischemia (SCI), 30-day mortality, and reintervention. Patients who had undergone LSA revascularization for LSA coverage in the Vascular Quality Initiative TEVAR database between 2011 and 2022 were identified. Patients with no coverage of the LSA, no LSA revascularization after LSA coverage, conversion to open repair, proximal disease > zone 5, distal zone disease < zone 3, and genetic history of connective tissue disease were excluded. We divided our cohort into two groups: open and endovascular revascularization of LSA. Open LSA revascularization was defined as treatment with surgical bypass. Endovascular LSA revascularization was defined as treatment with stent, stent graft, chimney, scallop, stented scallop, fenestration, stented fenestration, fenestrated branch, side-arm branch, and iliac device. Outcomes were perioperative stroke, AI, SCI, 30-day mortality, and reintervention. A total of 3052 patients met our inclusion criteria. There were 2396 (78.5%) patients in the open LSA revascularization group and 656 (21.5%) patients in the endovascular LSA revascularization group. The results are summarized in the Table. When compared with open LSA revascularization, endovascular LSA revascularization showed no significant difference in the risk of stroke (adjusted odds ratio [aOR]: 1.1, 95% confidence interval [CI]: 0.8-1.5; P = .498), AI (aOR: 1.5, 95% CI: 0.7-3.1; P = .273), SCI (aOR: 0.7, 95% CI: 0.3-1.5; P = .337), and 30-day mortality (aOR: 1.3, 95% CI: 0.8-2.0; P = .254). Furthermore, there was no significant difference in the risk of reintervention (aOR: 0.7, 95% CI: 0.4-1.2; P = .166). In this analysis of Vascular Quality Initiative data, both open and endovascular LSA revascularization for LSA coverage during TEVAR were equally effective and durable with no significant difference in outcomes of stroke, AI, SCI, 30-day mortality, and reintervention. Thus, endovascular LSA revascularization is a viable alternative to open LSA revascularization that could reduce the need for staged carotid-subclavian bypass or transposition procedures. Further studies are warranted to compare the long-term outcomes of open vs endovascular LSA revascularization, in addition to comparing the outcomes of specific endovascular techniques to each other.TableMultivariate logistic regression of stroke, arm ischemia (AI), spinal cord ischemia (SCI), 30-day mortality, and reintervention outcomesOutcomeEndovascular LSA revascularization vs open LSA revascularizationaOR (95% CI) (reference = open LSA revascularization)P valueStroke1.1 (0.8-1.5).498AI1.5 (0.7-3.1).273SCI0.7 (0.3-1.5).33730-day mortality1.3 (0.8-2.0).254Reintervention0.7 (0.4-1.2).166aOR, adjusted odds ratio; CI, confidence interval; LSA, left subclavian artery. Open table in a new tab

Abstract No. 503 Machine Learning Model to Predict Mid-Term All-Cause Mortality after Elective Thoracic Endovascular Aortic Repair for Thoracic Aortic Aneurysm

Abstract No. 503 Machine Learning Model to Predict Mid-Term All-Cause Mortality after Elective Thoracic Endovascular Aortic Repair for Thoracic Aortic Aneurysm

Thoracic Endovascular Aortic Repair with Supra-Aortic Trunk Revascularization is Associated with Increased Risk of Periprocedural Ischemic Stroke

Ischemic stroke is a devastating complication of thoracic endovascular aortic repair (TEVAR). This risk may be higher in more proximal aneurysms that require arch manipulation. The purpose of this study is to (1) describe 30-day stroke and death rates in patients undergoing TEVAR, (2) compare stroke rates in patients undergoing TEVAR for arch versus descending aneurysm pathology, and (3) identify predictive factors associated with stroke after TEVAR. The Vascular Quality Initiative registry was queried (2015-2021) for TEVAR procedures performed for degenerative aneurysms. Our primary outcomes were any stroke or death at 30 days. Patient-, procedure-, and hospital-level predictors of stroke were assessed using multivariable Poisson regression. Among 3,072 patients with degenerative aneurysms (197 [6.4%] arch versus 2,875 [93.6%] descending) treated with elective TEVAR, the median age was 73 years (interquartile range 67-79) and 54.8% were male. Within the arch aneurysm group, there were 27.4% zone 0, 22.8% zone 1, and 49.8% zone 2 interventions. Overall 30-day stroke and death rates were 3.2% and 3.8%. The distribution of stroke events was bilateral (52.9%), left carotid (20.7%), left vertebrobasilar (11.5%), right carotid (9.2%), and right vertebrobasilar (5.7%). Although mortality was similar between groups, the rate of ischemic stroke was higher for patients undergoing TEVAR for arch aneurysm versus descending aneurysms (7.1% arch versus 2.9% descending, P=0.001). Factors that were associated with ischemic stroke after TEVAR included age (>79years, relative risk [RR] 1.79, 95% confidence interval [CI] 1.08-2.98 vs. <79years), dependent functional status (RR 1.73, 95% CI 1.07-2.78), procedural time (RR 1.25, 95% CI 1.15-1.36), and endovascular intervention for supra-aortic trunk revascularization (RR 2.66, 95% CI 1.06-6.70 versus no intervention). Ischemic stroke risk after TEVAR was increased for arch aneurysms compared to descending aneurysms. More proximal zone coverage and endovascular interventions on the supra-aortic trunks were associated with increasing risk for stroke. Adequate preparation for stroke prevention is necessary prior to TEVAR with supra-aortic trunk revascularization.

Left Subclavian Artery Revascularization May Not Influence the Incidence of Spinal Cord Ischemia in Elective Thoracic Endovascular Aortic Aneurysm Repair

To analyze whether left subclavian artery (LSA) revascularization in patients undergoing elective thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm (TAA) is associated with decreased spinal cord ischemia (SCI). The national Vascular Quality Initiative TEVAR module was queried for all procedures performed between 2014 and 2021. Patients presenting with acute aortic dissections or aortic ruptures were excluded from the analysis. Only patients undergoing elective TEVAR for TAA and had their LSA covered during the procedure were included. Patients were divided into two groups according to their LSA revascularization (before or during TEVAR). A descriptive analysis was done to evaluate the change in frequency of LSA revascularization over the study interval. Univariate analysis was done to compare preoperative and intraoperative variables, and primary outcomes of SCI and cerebral stroke between the two groups. Among patients who had elective TEVAR for TAA, 669 patients had the LSA covered. The LSA was revascularized in 67% of these patients (n = 446). The incidence of LSA revascularization increased over the study period (Fig 1) (P < .001). Average age was 69 years, and 65% (n = 433) were male. Demographics and past medical history are summarized in Table I. Spinal cord ischemia developed in 20 patients (3%), and cerebral stroke in 29 patients (4%). No significant difference was seen when comparing postoperative SCI, cerebral stroke, 30-day or 1-year mortality between patients who had LSA revascularization and those who did not (Table II). Long-term survival did not differ between the two groups on Kaplan-Meier analysis (Fig 2). In patients with TAA undergoing elective TEVAR with LSA coverage, an increasing percentage of patients underwent preoperative or concomitant LSA revascularization over the course of the study—81% in 2021. In this study, LSA revascularization, however, did not aff5ct the incidence of postoperative SCI, cerebral stroke, or short or long-term mortality. In conclusion, LSA revascularization did not protect against SCI and may carry its own morbidity in elective TAAs requiring LSA coverage. More detailed studies are needed to help define the role of LSA revascularization in this setting.TableComparison of baseline characteristics, comorbidities, intraoperative variables, and postoperative outcomes between patients who had left subclavian artery (LSA) revascularization and those who did notOverall (n = 669)LSA nonrevascularized (n = 223)LSA revascularized (n = 446)P valueBaseline characteristics Age, years, mean (SD)69 (11)70 (11)69 (11).48 Gender, No. (%).69Male433 (65)142 (64)291 (65)Female236 (35)81 (36)155 (35) Race, No. (%).41African American115 (17)39 (18)76 (17)White474 (71)164 (74)310 (70)Others80 (12)20 (9)60 (14) BMI, mean (SD)28.4 (6.7)28.1 (6.8)28.5 (6.7).45 Smoking status, No. (%).94Never171 (26)59 (27)112 (25)Prior343 (51)113 (51)230 (52)Current154 (23)51 (23)103 (23)Medical History CVD, No. (%)81 (12)31 (14)50 (11).31 CAD, No. (%)111 (17)43 (19)68 (15).19 Congestive heart failure, No. (%)93 (14)33 (15)60 (13).63 COPD, No. (%)193 (29)73 (33)120 (27).12 Hypertension, No. (%)608 (91)199 (89)409 (92).22 Diabetes, No. (%)97 (14)38 (17)59 (13).19 Prior aortic surgery, No. (%)279 (42)103 (46)176 (40).10 Prior aneurysm repair, No. (%)226 (34)82 (36)145 (32).50Intraoperative variables Contrast volume, mL, mean (SD)118 (73)115 (72)120 (73).41 EBL, mL, mean (SD)243 (448)228 (399)251.2 (470).01 Fluoro time, minutes, mean (SD)23.2 (20.3)22.6 (23.0)23.5 (18.9).061 Procedure time, minutes, mean (SD)176 (100)158 (111)186 (94)<.01 Spinal drain placement, No. (%).38None343 (51.4%)111 (49.8%)232 (52.3%)Prophylactic311 (46.6%)106 (47.5%)205 (46.2%)Postoperative11 (1.6%)6 (2.7%)5 (1.1%)Outcomes Spinal cord ischemia, No. (%)20 (3)8 (4)12 (3).52 Cerebral stroke, No. (%)29 (4)9 (4)20 (5).79 30-Day mortality, No. (%)26 (4)5 (2)21 (5).12 1-Year mortality, No. (%)65 (10)21 (9)44 (10).85COPD, Chronic obstructive pulmonary disease; CVD, cerebrovascular disease; EBL, estimated blood loss; PCI, percutaneous coronary interventions; SD, standard deviation. Open table in a new tab Fig 2Kaplan-Meier curves comparing long-term survival between patients who underwent left subclavian artery (LSA) revascularization and those who did not.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Through and Through Wire Is the Unique Way to Force Tortuous Anatomy

A 67 year old male presented nine years after thoracic endovascular aortic repair (TEVAR) with a 98 mm thoracic aneurysm involving the ostium of the left subclavian artery, with a massive proximal type Ia endoleak. A carotid–subclavian bypass was created. Twenty-eight days later elective TEVAR (Zenith Alpha, Cook Medical, Bloomington, Indiana, USA) was carried out. Due to extreme tortuosity, the implantation required (A) a right femoral–right brachial (asterisk) through and through technique and inserting the proximal part of the delivery system (B) into the innominate artery (“Skewer technique”, arrow). The procedure was completed successfully, with no post-operative complications.Image 1

Utility of Psoas Muscle Area in Selecting Older Patients Feasible for Thoracic Endovascular Aortic Repair

BackgroundThe impact of psoas muscle area on overall survival is unknown for older patients undergoing elective thoracic endovascular aortic repair. MethodsWe retrospectively reviewed 105 patients aged 75 years or more who underwent elective thoracic endovascular aortic repair for descending thoracic aortic aneurysm between January 2010 and December 2019. Psoas muscle area was measured at the L3 level with preoperative computed tomography and adjusted by height squared to derive psoas muscle mass index. The patients were stratified into two groups, sarcopenia and nonsarcopenia. sarcopenia was defined as a psoas muscle mass index less than 5.40 cm2/m2 for men and less than 3.56 cm2/m2 for women. The overall survival was compared with the age- and sex-matched general population using the one-sample log rank test. The propensity score adjusted Cox proportional hazards model was applied to determine the hazard ratio for all-cause mortality. ResultsTwenty-three patients died during the follow-up period (median, 3 years). Thirty-eight patients (36%) were classified as sarcopenia. The 5-year overall survival rate was 46% (95% confidence interval, 29% to 73%) for sarcopenia and 84% (95% confidence interval, 74% to 94%) for nonsarcopenia. The overall survival was significantly lower in the sarcopenia group than in its matched general population (P = .004), whereas no statistically significant difference in overall survival was found between the nonsarcopenia group and its matched general population (P = .417). Sarcopenia was an independent risk factor for all-cause mortality (adjusted hazard ratio 2.64; 95% confidence interval, 1.02 to 6.82; P = .045). ConclusionsPsoas muscle mass index may be a good predictor of mortality among older patients undergoing elective thoracic endovascular aortic repair for descending thoracic aortic aneurysm.

TEVAR With Supra-Aortic Trunk Revascularization Is Associated With Increased Risk Of Periprocedural Ischemic Stroke

OBJECTIVE Ischemic stroke is a devastating complication of thoracic endovascular aortic repair (TEVAR). This risk may be higher in more proximal aneurysms that require arch manipulation. The purpose of this study was to (1) describe 30-day stroke and death rates in patients undergoing TEVAR, (2) compare stroke rates in patients undergoing TEVAR for arch versus descending aneurysm pathology, and (3) identify predictive factors associated with stroke after TEVAR. METHOD The Vascular Quality Initiative (VQI) registry was queried (2015-2021) for TEVAR procedures performed for degenerative aneurysm. Our primary outcomes were any stroke or death at 30-days. Patient-, procedure-, and hospital-level predictors of stroke were assessed using multivariable logistic regression. RESULT Among 3072 patients with degenerative aneurysms (197 [6.4%] arch vs. 2875 [93.6%] descending) treated with elective TEVAR, the median age was 73 (IQR 67-79) and 54.8% were male. Within the arch aneurysm group, there were 27.4% zone 0, 22.8% zone 1, and 49.8% zone 2 interventions. Overall 30-day stroke and death rates were 3.2% and 3.8%. The distribution of stroke events was bilateral (39.0%), left carotid (15.3%), left vertebrobasilar (8.5%), right carotid (6.8%), and right vertebrobasilar (4.2%). While mortality was similar between groups, the rate of ischemic stroke was higher for patients undergoing TEVAR for arch aneurysms versus descending aneurysms (7.1% arch vs. 2.9% descending, p=0.001). Factors that were associated with ischemic stroke after TEVAR included age (RR 1.06, 95% CI 1.03-1.09), operative time (RR 1.23, 95% CI 1.12-1.34), and endovascular intervention for supra-aortic trunk revascularization (RR 2.86, 95% CI 1.16-7.09 vs. no intervention). CONCLUSION Ischemic stroke risk after TEVAR was increased for arch aneurysms compared to descending aneurysms. More proximal zone coverage and endovascular interventions on the supra-aortic trunks were associated with increased risk for stroke. Adequate preparation for stroke prevention is necessary prior to TEVAR with supra-aortic trunk revascularization. Ischemic stroke is a devastating complication of thoracic endovascular aortic repair (TEVAR). This risk may be higher in more proximal aneurysms that require arch manipulation. The purpose of this study was to (1) describe 30-day stroke and death rates in patients undergoing TEVAR, (2) compare stroke rates in patients undergoing TEVAR for arch versus descending aneurysm pathology, and (3) identify predictive factors associated with stroke after TEVAR. The Vascular Quality Initiative (VQI) registry was queried (2015-2021) for TEVAR procedures performed for degenerative aneurysm. Our primary outcomes were any stroke or death at 30-days. Patient-, procedure-, and hospital-level predictors of stroke were assessed using multivariable logistic regression. Among 3072 patients with degenerative aneurysms (197 [6.4%] arch vs. 2875 [93.6%] descending) treated with elective TEVAR, the median age was 73 (IQR 67-79) and 54.8% were male. Within the arch aneurysm group, there were 27.4% zone 0, 22.8% zone 1, and 49.8% zone 2 interventions. Overall 30-day stroke and death rates were 3.2% and 3.8%. The distribution of stroke events was bilateral (39.0%), left carotid (15.3%), left vertebrobasilar (8.5%), right carotid (6.8%), and right vertebrobasilar (4.2%). While mortality was similar between groups, the rate of ischemic stroke was higher for patients undergoing TEVAR for arch aneurysms versus descending aneurysms (7.1% arch vs. 2.9% descending, p=0.001). Factors that were associated with ischemic stroke after TEVAR included age (RR 1.06, 95% CI 1.03-1.09), operative time (RR 1.23, 95% CI 1.12-1.34), and endovascular intervention for supra-aortic trunk revascularization (RR 2.86, 95% CI 1.16-7.09 vs. no intervention). Ischemic stroke risk after TEVAR was increased for arch aneurysms compared to descending aneurysms. More proximal zone coverage and endovascular interventions on the supra-aortic trunks were associated with increased risk for stroke. Adequate preparation for stroke prevention is necessary prior to TEVAR with supra-aortic trunk revascularization.

Surgical debranching versus branched endografting in zone 2 thoracic endovascular aortic repair

BackgroundLeft subclavian artery (LSA) revascularization has been recommended for patients undergoing elective thoracic endovascular aortic repair (TEVAR) with a proximal zone 2 landing requiring coverage of the LSA. The clinical standard of care remains surgical LSA revascularization. However, recently, the feasibility of using branched endografts has been demonstrated. We compared the perioperative and mid-term outcomes of these approaches. MethodsWe performed a retrospective review of consecutive patients who underwent TEVAR with a proximal zone 2 landing at a single center from 2014 to 2020. The patients were divided into cohorts for comparison: those who underwent surgical revascularization (SR-TEVAR group) and those who underwent thoracic branched endografting with an investigational device (TBE group). Those patients who did not undergo LSA revascularization were excluded. Perioperative outcomes, including procedural success, death, stroke, limb ischemia, and length of stay, were compared. Kaplan-Meier survival curves were compared using the log-rank test. The cumulative incidence of device-related endoleak (types I and III) and device-related reintervention, accounting for death as a competing hazard, were compared using the Fine-Gray test. ResultsA total of 55 patients were included: 31 (56%) in the SR-TEVAR group and 24 (44%) in the TBE group. The preoperative demographics and comorbidities were similar between the two groups. Procedural success was 100% in both cohorts, with no periprocedural strokes or left upper extremity ischemic events. One operative or 30-day death (TBE, 4.2%; vs SR-TEVAR, 3.2%; P = .99) occurred in each cohort. The total operative time (TBE, 203 ± 79 minutes; vs SR-TEVAR, 250 ± 79 minutes; P = .03) and total length of stay (TBE, 5.2 ± 3.6 days; vs SR-TEVAR, 9.9 ± 7.2 minutes; P = .004) were both significantly shorter in the TBE group. No difference was found in mid-term survival (log-rank test, P = .50) nor the cumulative incidence of device-related endoleak (Fine-Gray test, P = .51) or reintervention (Fine-Gray test, P = .72). No occlusions of the TBE graft or surgical bypass or transpositions had occurred after a mean follow-up of 28 ± 16 and 34 ± 24 months, respectively. ConclusionsTBE can be performed with procedural success rate and safety profile comparable to those of TEVAR with surgical revascularization, with a decreased total length of stay, for patients requiring proximal zone 2 coverage. The mid-term outcomes for each approach were also similar. Prospective, randomized comparisons of these techniques are warranted.

Comparison of Clinical Outcomes between Salvage and Elective Thoracic Endovascular Aortic Repair in Patients with Advanced Esophageal Cancer with Aortic Invasion: A Retrospective Cohort Study.

Aortoesophageal fistula (AEF) caused by esophageal cancer (EC) is a rare but life-threatening complication. However, the optimal management strategy remains undetermined. Previous cases have demonstrated that thoracic endovascular aortic repair (TEVAR) is effective for prophylactic management. In our study, we evaluated the management of AEF with elective TEVAR over salvage TEVAR. In our single-center retrospective cohort study, forty-seven patients with cT4M0 EC were included in this study, and we divided them into salvage (Group S) and elective (Group E) groups based on whether TEVAR was performed before the hemorrhagic AEF occurred. Our study outcomes included survival and complication rate after TEVAR. Group E showed better overall 90-day survival and aortic-event-free survival in 90-day and 180-day over Group S. More patients in Group E could receive subsequent chemoradiotherapy or esophagectomy. Significantly fewer AEF-related complications, including recurrent hemorrhagic events after TEVAR, hypoperfusion-related organ injury, and bloodstream infection, were noted in Group E. In patients with advanced EC-invading aorta, elective TEVAR offered an early overall and aortic-event-free survival benefit compared to salvage TEVAR. By reducing the AEF-related complications, elective TEVAR could provide more patients receiving subsequent curative-intent treatment.

C49. Hybrid Procedure in A Patient with Multiple Aortic Dissections and Marfan Syndrome: A Case Report

Abstract Background Aortic dissection is a tear in the inner layer of the aortic wall, which allows blood to enter into the wall of the aorta, creating a new passage for blood, known as the false lumen. The indications for surgical approach in aortic dissections Stanford A and DeBakey I and II are widely recognised and accepted, but little is known that in certain cases of Stanford A, DeBakey type I or type II aortic dissection patients who meet the eligibility criteria, endovascular repair can be performed. Case Illustration A 36-year-old woman came with a chief complaint of acute stabbed pain, she was known to have Concomitant DeBakey type II and IIIb aortic dissection, severe aortic regurgitation, and Marfan Syndrome. Because of her condition, we decided to conduct an open surgical repair with Bentall Procedure that was planned to be followed by an elective thoracic endovascular aortic repair (TEVAR). The Bentall procedure was a success and the patient’s clinical condition improved each day. Conclusion In concomitant DeBakey type II and IIIb aortic dissection cases, especially in those who have an underlying condition such as Marfan Syndrome, the Bentall procedure is the treatment of choice. In conditions when surgical procedure cannot be done, a hybrid approach of open surgery and TEVAR may provide a valuable alternative for patients.

C49. Hybrid Procedure in A Patient with Multiple Aortic Dissections and Marfan Syndrome: A Case Report

Abstract Background Aortic dissection is a tear in the inner layer of the aortic wall, which allows blood to enter into the wall of the aorta, creating a new passage for blood, known as the false lumen. The indications for surgical approach in aortic dissections Stanford A and DeBakey I and II are widely recognised and accepted, but little is known that in certain cases of Stanford A, DeBakey type I or type II aortic dissection patients who meet the eligibility criteria, endovascular repair can be performed. Case Illustration A 36-year-old woman came with a chief complaint of acute stabbed pain, she was known to have Concomitant DeBakey type II and IIIb aortic dissection, severe aortic regurgitation, and Marfan Syndrome. Because of her condition, we decided to conduct an open surgical repair with Bentall Procedure that was planned to be followed by an elective thoracic endovascular aortic repair (TEVAR). The Bentall procedure was a success and the patient’s clinical condition improved each day. Conclusion In concomitant DeBakey type II and IIIb aortic dissection cases, especially in those who have an underlying condition such as Marfan Syndrome, the Bentall procedure is the treatment of choice. In conditions when surgical procedure cannot be done, a hybrid approach of open surgery and TEVAR may provide a valuable alternative for patients.

Abstract 10046: Racial Disparity in Patients Undergoing Thoracic Endovascular Aortic Repair for Thoracic Aortic Aneurysms and Dissections

Introduction: Thoracic Endovascular Aortic Repair (TEVAR) has become the standard of care for treating complicated type B aortic dissection and descending thoracic aortic aneurysms. There are no large datasets evaluating racial disparities in patients undergoing TEVAR. Hypothesis: There is no difference in outcomes between patients of different ethnicities and race undergoing TEVAR. Methods: We analyzed adult patients who underwent TEVAR for complicated type B aortic dissection or descending thoracic aortic aneurysm. International Classification of Diseases, Ninth Revision, were used to identify patients. We utilized the National Inpatient Sample database, from January 1, 2010 to December 31, 2017. Appropriate trend weights were used to generate national estimates. Primary outcome measure was in hospital mortality. Predictors of mortality were determined using hierarchical logistic regression and a mixed logistic model was used to account for hospital variations. Excluded patients were less than 18 years old. Results: The study population consisted of 25260 patients. There were 17197 (68.07%) white patients, 4959 (19.66%) black patients, 1462 (5.74%) Hispanic patients and 1642 (6.51%) patients of various other ethnicities and races. Although the Elixhauser comorbidity index was not significantly different between groups, white patients were older, underwent more elective repairs, had lower baseline rates of diabetes mellitus, hypertension and chronic kidney disease. There was no significant difference when comparing in hospital mortality between white (reference group), black (OR 0.86, p=0.46), Hispanic (OR 1.54, p=0.13) or other groups (OR 0.78, p=0.45). Non elective TEVAR (OR 2.23, p&lt;0.001), presence of other cardiac conditions (OR 2.68, p&lt;0.001), and preoperative diagnosis of cerebral vascular disease (OR 2.39, p&lt;0.001), peripheral vascular disease (OR 1.62, p=0.00) and chronic kidney disease (OR 1.45, p=0.04) were significant predictors of in hospital mortality. Conclusions: While patients of color were older and had more peripheral vascular disease and chronic obstructive pulmonary disease racial differences did not predict in hospital mortality.

Outcomes of Thoracic Endovascular Aortic Repair in Octogenarians.

The aim of this study is to compare outcomes between octogenarians and non-octogenarians undergoing thoracic endovascular aortic repair (TEVAR). Using the National Inpatient Sample database, we identified octogenarians (≥80years) and non-octogenarians (<80years) who had undergone thoracic endovascular aortic repair between 2012 and 2017. We compared patients' demographic, socioeconomic, comorbidity data between the two groups as well as the procedure indications and perioperative outcomes. A multivariable logistic regression analysis was conducted to evaluate the impact of advanced age (≥80years) on the in-hospital mortality rates in patients who underwent TEVAR. This analysis was also performed for a separate cohort which included only patients who underwent TEVAR for ruptured thoracic aortic aneurysm. A total of 4108 patients were included in our study; 3432 (83.5%) patients were <80years (37.9% female; median age, 64years; 34.3% non-white) and 676 (16.5%) patients were ≥80 years (50.7% female; median age, 83 years; 20.4% non-white). Non-ruptured thoracic aortic aneurysm was the most common indication for TEVAR in older patients (61.4%), whereas type B aortic dissection was the most common indication in younger patients (36.4%). In-hospital complications were comparable between the two groups except for respiratory complications that were higher in the younger patients (21.2% vs. 15.2%; P <.001). The multivariable analysis demonstrated that advanced age had no association with increased in-hospital mortality rates (adjusted odds ratio [aOR], 1.41; 95% confidence interval [CI], .97-2.05), However, in ruptured thoracic aortic aneurysm cohort, octogenarians had higher in-hospital mortality rates (aOR, 1.86; 95% CI, 1.04-3.32). Octogenarians have acceptable rates of perioperative morbidity and mortality compared to the younger group and should be considered for TEVAR. Octogenarians are at higher risk for in-hospital mortality in the setting of ruptured thoracic aortic aneurysm, supporting the appropriateness of elective TEVAR in selected Octogenarians.

A Case of Multilevel Aortic Disease Treated Using Cardiatis Multilayer Flow Modulator.

A recent systematic review and meta-analysis shows that synchronous and metachronous thoracic and abdominal aortic aneurysms are present in 19.2% of cases. The management remains controversial: elective simultaneous TEVAR and EVAR could increase morbidity due to increased aortic coverage during a single procedure, longer operative times, increased blood loss, and greater contrast exposure. Conversely, simultaneous thoracic endovascular aortic repair (TEVAR) and endovascular aneurysms repair (EVAR) prevent the need for two interventions, reduces future access site complications, and obviates interval aortic complications.We present a case of a multilevel aortic disease treated in three stages: EVAR, TEVAR, and exclusion of an increasing aortic visceral penetrating aortic ulcer through a multilayer flow modulator endograft with an optimal result.

Influence of sex after elective thoracic endovascular aortic repair

Influence of sex after elective thoracic endovascular aortic repair

Preoperative statin therapy is associated with higher 5-year survival after thoracic endovascular aortic repair

ObjectiveStatin use is associated with higher long-term survival after abdominal aortic aneurysm repair. However, the association between statin use and survival after thoracic endovascular aortic repair (TEVAR) has not been established. MethodsWe performed a review of prospectively collected data of all patients who had undergone TEVAR in the Vascular Quality Initiative between 2014 and 2020. We excluded patients aged <18 years, those who had presented with trauma, and those who had received custom-manufactured or physician-modified devices. We evaluated the association between preoperative statin therapy and in-hospital mortality and complications and 5-year mortality. We also analyzed the trend of preoperative statin use in elective cases for the previous 7 years. To account for nonrandom assignment to treatment, we used propensity score matching of patient characteristics, comorbidities, pathology, and urgency for preoperative statin use. We used logistic regression and Cox regression for the short-term and 5-year outcomes, respectively. ResultsOf 6266 patients who had undergone TEVAR and met the inclusion criteria, 3331 (53%) patients had been taking a statin preoperatively, including 1148 of 2267 (64%) treated for aneurysmal disease. After propensity score matching, 1875 patients were in each cohort. Preoperative statin use was associated with lower rates of any perioperative complication (16.7% vs 19.6%; odds ratio, 0.82; 95% confidence interval [CI] 0.69-0.97; P = .022). Overall, preoperative statin use was also associated with lower 5-year mortality (18.8% vs 24.5%; hazard ratio [HR], 0.74; 95% CI, 0.63-0.89; P = .001). When stratified by urgency, preoperative statin use was associated with lower 5-year mortality after elective TEVAR (14.9% vs 22.4%; HR, 0.62; 95% CI, 0.49-0.79; P < .001) but not after urgent or emergent TEVAR (27.4% vs 29.1%; HR, 0.89; 95% CI, 0.70-1.14; P = .37). When stratified by pathology, preoperative statin use was associated with significantly lower 5-year mortality for patients with aneurysms (HR, 0.63; 95% CI, 0.48-0.83; P = .001). Although the mortality was also lower for patients with dissection and “other” pathology, these differences did not reach statistical significance. Between 2014 and 2019, a significant increase had occurred in statin use among patients undergoing elective TEVAR, from 56% in 2014 to 64% in 2019 (P = .007). ConclusionsPreoperative statin therapy is associated with lower perioperative complication rates and 5-year mortality for patients undergoing TEVAR. All patients with known thoracic aortic pathology should receive statin therapy unless contraindications for the drug are present. For patients undergoing elective TEVAR, the statin prescription percentage should be considered a quality metric, and further implementation research should occur to improve preoperative statin use.

A novel preoperative risk score for nonhome discharge after elective thoracic endovascular aortic repair

BackgroundNonhome discharge (NHD) to a rehabilitation or skilled nursing facility after vascular surgery is poorly described despite its large impact on patients. Understanding postsurgical NHD risk is essential to providing adequate preoperative counseling and shared decision making, particularly for elective surgeries. We aimed to identify independent predictors of NHD after elective thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysms (TAA) and to create a clinically useful preoperative risk score. MethodsElective TEVAR cases for descending TAA were queried from the Society for Vascular Surgery Vascular Quality Initiative from 2014 to 2018. A risk score was created by splitting the dataset into two-thirds for model development and one-third for validation. A parsimonious stepwise hierarchical multivariable logistic regression controlling for hospital level variation was performed in the development dataset, and the beta-coefficients were used to assign points for a risk score. This score was then cross-validated and model performance assessed. ResultsOverall, 1469 patients were included and 213 (14.5%) required NHD. At baseline, patients who required NHD were more likely to be ≥80 years old (35.2% vs 19.4%), female (58.7% vs 40.6%), functionally dependent (42.3% vs 24.0%), and anemic (46.5% vs 27.8%), and to have chronic obstructive pulmonary disease (41.3% vs 33.4%), congestive heart failure (18.8% vs 11.1%), and American Society of Anesthesiologists class ≥4 (51.6% vs 39.8%; all P < .05). Multivariable analysis in the development group identified independent predictors of NHD that were used to create an 18-point risk score. Patients were stratified into three groups based upon their risk score: low risk (0-7 points; n = 563) with an NHD rate of 4.3%, moderate risk (8-11 points; n = 701) with an NHD rate of 17.0%, and high risk (≥12 points; n = 205) with an NHD rate of 34.2%. The risk score had good predictive ability with a c-statistic of 0.75 for model development and a c-statistic of 0.72 in the validation dataset. ConclusionsThis novel risk score can predict NHD after TEVAR for TAA using characteristics that can be identified preoperatively. The use of this score may allow for improved risk assessment, preoperative counseling, and shared decision making.

Thoracic Endovascular Aortic Repair With Left Subclavian Artery Coverage Is Associated With High 30-Day Stroke Incidence With or Without Concomitant Revascularization

Review of the National Surgical Quality Improvement Program registry from 2005 to 2017 The stroke incidence was 2% after elective thoracic endovascular aortic repair (TEVAR) without left subclavian artery (LSA) coverage compared with 5% with LSA coverage (P < .001). In TEVARs with LSA coverage, the stroke incidence was 7.5% when the LSA was concomitantly revascularized vs 4.4% without concomitant revascularization. LSA coverage was significantly associated with stroke both with and without concomitant revascularization. Stroke after TEVAR with LSA coverage occurs frequently in the real-world setting, and concurrent LSA revascularization was not associated with a lower stroke incidence.