Prior Aortic Surgery Research Articles

Predictors for length of stay after surgical aortic valve replacement.

Aortic valve replacement improves and prolongs lives of patients with aortic valve disease, but requires significant healthcare resources, which are mainly determined by the length of associated hospital stays. Therefore, this study aims to identify risk factors for extended length of stay after surgical aortic valve replacement. Between 2018 and 2023, 458 consecutive patients underwent isolated surgical aortic valve replacement at our center and were included in our analysis. To identify independent predictors for hospital and intensive care unit stay, multivariable linear regression analysis using backward elimination process was performed. Upon multivariable linear regression, endocarditis [regression coefficient (β) 2.98; 95% confidence interval (CI) 1.51, 4.45; p<0.001)] and prior aortic valve surgery (β 1.72; 95% CI 0.18, 3.26; p=0.029) were associated with prolonged hospital stay. Prior aortic valve surgery was associated with prolonged intensive care unit stay (β 0.99; 95% CI 0.39, 1.59; p=0.001) as well as chronic obstructive pulmonary disease (β 1.61; 95% CI 0.66, 2.55; p=0.001), smaller prosthetic valve sizes (β -0.18; 95% CI -0.30, -0.06; p=0.003), preoperative atrial fibrillation (β 1.06; 95% CI 0.32, 1.79; p=0.005), and reduced left ventricular ejection fraction (β -0.03; 95% CI -0.05, -0.01; p=0.006). Pending further validation, structured programs aiming to accelerate intensive care unit and hospital discharge after surgical aortic valve replacement should focus on patients with prior cardiac surgery, atrial fibrillation, and chronic obstructive pulmonary disease. Surgeons should aim to implant large-diameter valves. Furthermore, the identified predictors should be used to discuss surgical versus transcatheter procedures in the interdisciplinary heart team.

Operative Times and Outcomes of Complex Endovascular Repairs of Thoracoabdominal Aneurysms

IntroductionOwing to the significant morbidity and mortality of open thoracoabdominal aortic aneurysm surgery, complex endovascular repairs (eTAAA) have become increasingly common, but still carry substantial risk. These repairs require large bore access, with resultant pelvic and lower extremity ischemia. We therefore hypothesized that operative timing would be associated with outcomes, as efficient surgery would limit the ischemic time as well as anesthesia time. MethodsWe studied all eTAAA repairs (Crawford Types 1-3, 5) incorporating at least one branch vessel from 2014 to 2021 in the Vascular Quality Initiative, and categorized them into quartiles of total operating time. To account for variations in case complexity and intraoperative events, we performed a sub-analysis stratifying each surgeon by their median operating time. Multilevel logistic regression was employed to compare perioperative outcomes including mortality, thoracoabdominal life altering events (TALE:composite of perioperative death, stroke, permanent paralysis and/or dialysis), spinal cord ischemia (SCI), acute kidney injury (AKI), major adverse cardiac events (MACE), myocardial infarction, and dialysis. ResultsThere were 2,925 eTAAA repairs during the study period. Procedure times ranged from <204 minutes in the first quartile to >365 minutes in the fourth. Longer cases more commonly involved older patients who were more often female, and higher rates of prior stroke, and preoperative anemia. They involved larger, more extensive aneurysms, with higher rates of prior aortic surgery, and more commonly employed PMEGs or parallel grafting to incorporate more branch vessels. In addition, they were less often staged procedures, and used more spinal drains, femoral cutdowns, and upper extremity access. Operating time decreased as experience increased. In adjusted analyses, the odds of mortality and every morbidity studied increased stepwise with operating time, with 4 to 13-fold higher odds in the highest quartiles. Spinal cord ischemia had the strongest association with procedure times, with seven-fold higher odds (OR 7.2 [2.9-17.9], P<.001) of any SCI in the highest quartile compared to the lowest, and 13-fold higher odds of permanent SCI (OR 13.1 [3.9-44.7], P<.001). These results were consistent when surgeons were grouped into quartiles by their median operating times. Medium-term mortality was also higher in the upper quartile of operating time (HR 2.7 [1.4-5.1], P=.002). ConclusionLonger operating times for complex eTAAA repairs were associated with markedly higher rates of morbidity and mortality, especially spinal cord ischemia. These results emphasize the importance of expeditious repairs by experienced teams.

Elective root replacement increases the risk of type B dissection in patients with Marfan syndrome

ObjectiveMarfan syndrome is a genetic disorder with increased risk of aortic dissection. Currently, type A aortic dissection risk is mitigated by aortic root replacement with Dacron. It is unclear if root replacement increases the risk of distal aortic disease given the noncompliant nature of Dacron. MethodsAll adult patients with a diagnosis of Marfan syndrome at a single academic center, excluding those with history of dissection or concomitant arch repair, were studied (n = 322). Student t test or Wilcoxon Mann–Whitney test was used for continuous variables; chi-square or Fisher exact test was used for categorical variables. Propensity matching used age, sex, hypertension, race, body mass index, family history of Marfan syndrome, and genetic mutational class. Differences in freedom from type B aortic dissection were determined using the log-rank test. ResultsA total of 124 patients underwent root replacement compared with 198 patients with no prior aortic surgery. Median follow-up time was 9.90 years. Male sex, weight, and hypertension prevalence were higher in the root replacement group (P < .05). Distribution of fibrillin-1 mutations was homogenous (P > .9). Type B aortic dissection frequency in the root replacement group was higher (21% [n = 20] vs 4.2% [n = 4], P < .001). Aortic-related mortality was higher in the root replacement group (11% [n = 14] vs 3.5% [n = 7], P < .01). Distal aortic intervention frequency was higher in the root replacement group (P = .009). ConclusionsPatients with Marfan syndrome who undergo elective aortic root replacement appear to have a higher incidence of subsequent type B aortic dissection, independent of other risk factors. Careful consideration must be made to the management of the distal aorta in patients with Marfan syndrome who undergo root replacement.

Outcomes using inverted iliac limb bifurcate components in fenestrated/branched endografting

BackgroundThe use of standard bifurcate pieces in fenestrated/branched endovascular aortic repair (F/BEVAR) requires adequate length from the lowest branch or fenestration to the aortic bifurcation. In patients with prior aortic surgery, the aortic bifurcation is often artificially established in a more proximal position, compromising the infrarenal length, which hinders the placement of a standard bifurcate component below the fenestrated/branched component. Short bifurcate bodies using an inverted contralateral limb have been purpose-built to address this challenge. However, reported outcomes for this device remain limited, with specific concerns about the durability of the inverted iliac limb sealing region. We sought to evaluate outcomes of F/BEVAR using an investigational inverted iliac limb bifurcate, manufactured by Cook Medical. MethodsThis study was a retrospective review of prospectively maintained data from the US-Aortic Research Consortium from 2005 to 2022. Patients were included if they underwent F/BEVAR for thoracoabdominal or complex abdominal aortic aneurysms. Patients were excluded if they did not have a bifurcate device placed. Patients were then compared based on the use of an inverted iliac limb or standard bifurcate component. The primary outcome for this study was technical success. Secondary outcomes included 30-day mortality, freedom from ischemic leg complications, freedom from type I endoleaks (TIELs), freedom from type II endoleaks (TIIELs), freedom from type III endoleaks (TIIIELs), and graft component separations. ResultsA total of 1944 patients met study criteria with 442 (22.8%) inverted iliac limb bifurcates and 1502 (77.2%) standard bifurcates. Patients who received inverted iliac limbs were more likely to have had prior aortic surgery (63.8% vs 28.5%; P < .001). Patients receiving inverted iliac limbs had longer procedure times (265 minutes; interquartile range [IQR], 201-342 minutes vs 241 minutes; IQR, 186-313 minutes; P < .001), more contrast use (89 mL [IQR, 55-135 mL] vs 109 mL [IQR, 75-156 mL]; P < .001), and higher estimated blood loss (250 mL [IQR, 150-500 mL] vs 250 mL [IQR, 110-400 mL]; P = .042). There were no differences in rates of technical success (97.3% vs 96.1%; P = .310), rates of endoleaks upon completion of the case (18.0% vs 21.4%; P = .123), or 30-day mortality rates (1.8% vs 2.5%; P = .466) between patients receiving inverted iliac limb and standard bifurcated components. There were no differences in cumulative survival, freedom from limb ischemia, freedom from aneurysm rupture, and freedom from TIIIELs over the course of 5 years between patients receiving inverted bifurcates and standard bifurcated components. Patients with inverted iliac limb bifurcate components had decreased freedom from reinterventions, TIELs, and TIIELs. After adjustment for potential confounders, the use of an inverted iliac limb was not associated with reinterventions (hazard ratio,1.044; 95% confidence interval, 0.849-1.285; P = .682). There was a total of 2 component separations (0.1%) of the bifurcate component from the fenestrated/branched component over the study period, both of which occurred in the standard bifurcate components. ConclusionsThe use of investigational inverted iliac limb bifurcate components is a safe option with favorable mid-term outcomes in patients who are not anatomical candidates for standard bifurcate components. Patients undergoing investigational inverted iliac limb bifurcate component implantation had decreased freedom from reinterventions, which likely corresponds with the complexity of repair associated with them.

Duplex Ultrasound–Only Surveillance after Endovascular Abdominal Aortic Aneurysm Repair is Associated with Favorable Long-Term Outcomes

ObjectiveLong-term data surrounding the impact of different endovascular abdominal aortic aneurysm repair (EVAR) surveillance strategies is limited. Therefore, the purpose of this study was to characterize postoperative imaging patterns, as well as to evaluate the association of duplex ultrasound surveillance after the first postoperative year with 5-year EVAR outcomes. MethodsEVAR patients (2003-2016), who survived at least 1-year without aneurysm rupture, conversion to open repair, and reintervention in the Vascular Implant Surveillance and Interventional Outcomes Network (VISION) were examined to provide all subjects ≥3-years of follow-up time. Patients were categorized into 6 cohorts after the first postoperative year: No imaging (N=953); CT/MRI-only (N=2,976); Duplex ultrasound-only (DUS; N=1,808); Combined CT/MRI+DUS with >50% being CT/MRI (N=1,937); Combined CT/MRI+DUS with >50% being DUS (N=2,253); and Mixed (CT+DUS+MRI-N=1,272). Abdominal aortic aneurysm (AAA) related re-intervention, rupture, conversion to open repair, and all-cause mortality were estimated using Kaplan-Meier analysis. Multivariable logistic regression models identified variables associated with using DUS-only imaging (vs. CT/MRI only). Cox regression models compared 5-year outcomes between patients receiving DUS-only vs. CT/MRI-only imaging. ResultsA total of 11,199 EVAR patients were examined (mean age-76±7 years; female-20%; non-elective-10%). DUS-only imaging surveillance after the first postoperative year was more likely to occur after elective repairs, as well as among older, male patients. Smaller (<6cm) preoperative AAA diameter and absence of documented concurrent iliac aneurysm was also associated with DUS-only follow-up. Additionally, no endoleak detection on index EVAR completion imaging, as well as a documented >5mm decrease in AAA sac diameter at 1-year follow-up was more common with DUS-only surveillance protocols. Post-EVAR DUS-only imaging after the first postoperative year had the lowest incidence of re-intervention, conversion to open repair, and rupture (as well as the composite reintervention/open conversion/rupture; log-rank P<.001 for all). Further, patients receiving exclusively DUS after their first postoperative year had better overall survival (log-rank P<.001). These outcome advantages that were associated with DUS-only surveillance compared with CT/MRI-only surveillance after EVAR persisted when controlling for baseline co-variates, preoperative AAA diameter, prior aortic surgery history, sac growth, and presence of endoleak (all P<.01). ConclusionsEVAR patients selected for DUS-only surveillance after the first postoperative year have excellent freedom from AAA-related reintervention, conversion to open repair, rupture and all-cause mortality. These findings remained on multivariable analysis after adjusting for baseline characteristics, endoleak status and sac diameter changes within the first year. This is the first registry-based investigation to document long-term EVAR outcomes for patients entered into a DUS-only monitoring protocol which serves to corroborate the growing evidence base that DUS may be able to supplant CT surveillance in certain subgroups. A prospective randomized multi-center trial comparing DUS versus CT-based imaging after EVAR is needed to validate these findings which may serve to change current practice guidelines, as well as industry and regulatory stakeholder requirements.

The effect of incremental increases in the number of packed red blood cell units transfused on perioperative outcomes in open abdominal aortic aneurysm repair.

Despite abundant evidence in the surgical and critical care literature demonstrating inferior outcomes in transfused patients, liberal use of blood transfusion, particularly after the initial unit, remains common in vascular surgery. We therefore sought to investigate the incremental risk of each additional unit of blood transfused intraoperatively for patients undergoing elective open repair of abdominal aortic aneurysm (AAA) with regards to postoperative mortality and complications. Patients in the Vascular Quality Initiative registry undergoing elective open infrarenal AAA repair from 2003 to 2020 were included. Exclusion criteria were age greater than 90, prior aortic surgery, concomitant iliac aneurysm, and concomitant additional major procedure. Multivariable logistic regression was used to calculate adjusted odds ratios for in-hospital mortality with incremental increases in packed red blood cells (pRBCs) given intraoperatively. Univariate analysis was performed for secondary outcomes including postoperative cardiac, respiratory, renal, and wound complications. Of 4608 patients who underwent elective open AAA repair, 796 patients (16.9%) underwent perioperative transfusion. The overall in-hospital mortality rate was 2.5%. Adjusting for relevant factors, there was an increase in the odds of in-hospital mortality of 24% for each additional unit transfused. Incremental increases in the number of units transfused were associated with significantly higher risk of postoperative myocardial infarction, congestive heart failure, pulmonary complications, renal failure, and wound complications. There appears to be an important increase in the odds of mortality for each additional unit transfused during infrarenal open AAA repair even when controlling for confounders.

Assessment of fitness for open repair in patients with infrarenal abdominal aortic aneurysms

ObjectiveEndovascular aortic repair (EVAR) was originally designed as a treatment modality for patients with abdominal aortic aneurysms (AAAs) deemed unfit for open repair. However, the definition of “unfit for open repair” is largely subjective and heterogenous. The purpose of this study was to compare patients deemed unfit for open repair who underwent EVAR to a matched cohort who underwent open repair for infrarenal AAAs. MethodsThe Vascular Quality Initiative of the Society for Vascular Surgery was queried for patients who underwent EVAR and open infrarenal AAA repair from 2003 to 2022. Patients that underwent EVAR were included if they were deemed unfit for open repair by the operating surgeon. EVAR patients deemed unfit because of a hostile abdomen were excluded. Patients in both the open and EVAR datasets were excluded if their repair was deemed non-elective or if they had prior aortic surgery. EVAR patients were matched to a cohort of open patients. The primary outcome for this study was 1-year mortality. Secondary outcomes included 30-day mortality, major adverse cardiac events, pulmonary complications, non-home discharge, reinterventions, and 5-year survival. ResultsA total of 5310 EVAR patients were identified who were deemed unfit for open repair. Of those, 3028 EVAR patients (57.0%) were able to be matched 1:1 to a cohort of open patients. Open patients had higher rates of major adverse cardiac events (20.2% vs 4.4%; P < .001), pulmonary complications (12.8% vs 1.6%; P < .001), non-home discharges (28.5% vs 7.9%; P < .001), and 30-day mortality (4.5% vs 1.4%; P < .001). There were no differences in early survival, but open repair had better middle and late survival compared with EVAR over the course of 5 years. A total of 74 EVAR patients (2.4%) had reinterventions during the study period. EVAR patients that required interventions had higher 1-year (40.5% vs 7.3%; P < .001) and 5-year mortality (43.2% vs 14.1%; P < .001) compared with those that did not require reinterventions. EVAR patients who had reinterventions had higher 1-year (40.5% vs 6.3%; P < .001) and 5-year (43.2% vs 20.3%; P = .006) mortality compared with their matched open cohort. ConclusionsPatients undergoing EVAR for AAAs who are deemed unfit for open repair have better perioperative morbidity and mortality compared with open repair. However, patients who had an open repair had better middle and late survival over the course of 5 years. The categorization of unfitness for open surgery may be inaccurate and re-evaluation of this terminology/concept should be undertaken.

Prospective randomized pilot trial comparing prophylactic and therapeutic cerebrospinal fluid drainage during complex endovascular thoracoabdominal aortic aneurysm repair

BackgroundEndovascular techniques have transformed the management of thoracoabdominal aortic aneurysms (TAAAs). However, spinal cord ischemia (SCI) remains a prevalent and devastating complication. Prophylactic drainage of cerebrospinal fluid (CSF) is among the proposed strategies for prevention of SCI. Although prophylactic CSF drainage is widely used and conceptually attractive, prophylactic CSF drains have not been demonstrated to definitively prevent the occurrence nor mitigate the severity of SCI in endovascular TAAA repair. Whether or not outcomes of prophylactic drains are superior to therapeutic drains remains unknown. This pilot study was performed to determine the feasibility of a randomized clinical trial designed to investigate the role of prophylactic vs therapeutic CSF drains in the prevention of SCI in patients undergoing endovascular TAAA repair using branched and fenestrated endovascular aortic repair (FBEVAR). MethodsThis was a prospective multicenter randomized pilot clinical trial conducted at The University of Alabama at Birmingham and The University of Massachusetts. Twenty patients were enrolled and randomized to either the prophylactic drainage or therapeutic drainage groups, prior to undergoing FBEVAR for extensive TAAAs and arch aortic aneurysms. This was a pilot feasibility study that was not powered to detect statistical differences in clinical outcomes. The primary outcome was feasibility of randomization and compliance with a shared lumbar drain protocol. Secondary outcomes included rate of drain complications and SCI. ResultsTwenty patients were enrolled and successfully randomized, without any crossovers, to either the control cohort (n = 10), without prophylactic drains, or the experimental cohort (n = 10), with prophylactic drains. There were no differences in age, comorbidities, or history of prior aortic surgery across the cohorts. All patients were treated with FBEVAR. Aneurysm classifications were as follows: Extent I (10%), Extent II (50%), Extent III (35%), and Extent IV (5%). The average length of aortic coverage was 207 ± 21.6 mm. The length of aortic coverage did not vary across cohorts, nor did procedural times or blood loss volume. Compliance with the SCI prevention protocol was 100% across both groups. Within the prophylactic drain cohort, one patient experienced an adverse event related to lumbar drain placement, manifested as an epidural hematoma requiring laminectomy, without neurologic deficit (n = 1/10; 10%). There was one SCI event (n = 1/20; 5%), which occurred in the prophylactic drain cohort on postoperative day 9 following an episode of hypotension related to a gastrointestinal bleed. ConclusionsThe role of prophylactic CSF drains for the prevention of SCI following endovascular TAAA repair is a topic of ongoing research, with many current practices based on expert opinion and experience, rather than rigorous scientific data. This study demonstrates the feasibility of a multicenter randomized clinical trial to evaluate the role of prophylactic vs therapeutic CSF drains in the prevention of SCI in patients undergoing endovascular TAAA repair.

Reinterventions and sac dynamics after fenestrated endovascular aortic repair with physician-modified endografts for index aneurysm repair and following proximal failure of prior endovascular aortic repair

ObjectiveThe high frequency of reinterventions after fenestrated endovascular aortic repair (FEVAR) with physician-modified endografts (PMEGs) has been well-studied. However, the impact of prior EVAR on reinterventions and sac behavior following these procedures remains unknown. We analyzed 3-year rates of reinterventions and sac dynamics following PMEG for index aneurysm repair compared with PMEG for prior EVAR with loss of proximal seal. MethodsWe performed a retrospective analysis of 122 consecutive FEVARs with PMEGs at a tertiary care center submitted to the United States Food and Drug Administration in support of an investigational device exemption trial. We excluded patients with aortic dissection (n = 5), type I to III thoracoabdominal aneurysms (n = 13), non-elective procedures (n = 4), and prior aortic surgery other than EVAR (n = 8), for a final cohort of 92 patients. Patients were divided into those who underwent PMEG for index aneurysm repair (primary FEVAR) and those who underwent PMEG for rescue of prior EVAR with loss of proximal seal (secondary FEVAR). The primary outcomes were freedom from reintervention and sac dynamics (regression as ≥5 mm decrease, expansion as ≥5 mm increase, and stability as <5 mm increase or decrease) at 3 years. Secondary outcomes were perioperative mortality and 3-year survival. ResultsOf the 92 patients included, 56 (61%) underwent primary FEVAR and 36 (39%) underwent secondary FEVAR. Secondary FEVAR patients were older (78 years [interquartile range (IQR), 74.5-83.5 years] vs 73 years [IQR, 69-78.5 years]; P < .001), more frequently male (86% vs 68%; P = .048), and had larger aneurysms (72.5 mm [IQR, 65.5-81 mm] vs 59 mm [IQR, 55-65 mm]; P < .001). Perioperative mortality was 1.8% for primary FEVAR and 2.7% for secondary FEVAR (P = .75). At 3 years, overall survival was 84% for primary FEVAR and 71% for secondary FEVAR (P = .086). Freedom-from reintervention was significantly higher for primary FEVAR than secondary FEVAR, specifically 82% vs 38% at 3 years (P < .001). Primary FEVAR also had more desirable sac dynamics relative to secondary FEVAR at 3 years (primary: 54% stable, 46% regressed, 0% expanded vs secondary: 33% stable, 28% regressed, and 39% expanded; P = .038). ConclusionsFEVAR for primary aortic repair and FEVAR for rescue of prior EVAR with loss of proximal seal are two distinct entities. Following primary FEVAR, less than a quarter of patients have undergone reintervention at 3 years, and sac expansion was not seen in our cohort. Comparatively, 3 years after secondary FEVAR, over one-half of patients have undergone reintervention and over one-third have had ongoing sac expansion. Vigilant surveillance and a low threshold for further interventions are crucial following secondary FEVAR.

A Comparison of Surgical Techniques and Outcomes for Primary Infected Abdominal Aortic Aneurysms

Primary infected abdominal aortic aneurysms (PIAAAs) are associated with high morbidity and mortality. Three repair approaches include open in-situ repair (OIR), extra-anatomic repair (EAR), and endovascular abdominal aortic aneurysm repair (EVAR). This study is one of the largest single-center case series comparing the outcomes of the different surgical approaches for PIAAA. This is a retrospective cohort study of all patients treated surgically for PIAAA between 2000 and 2021. PIAAA diagnosis was defined as the presence of an abdominal aortic aneurysm with evidence of infection on clinical presentation, laboratory markers, radiology, or surgically. Patients with prior aortic surgery were excluded from this study. Basic demographics were compared across the 3 surgical groups using standard statistical methods. Our primary outcomes included mortality at 1 and 5 years. Kaplan-Meier curves were generated and compared using log-rank testing. Multivariate Cox proportional hazards models were created to assess determinants of mortality. A total of 43 patients were included in the full cohort. Patients undergoing EVAR more often had diabetes, end-stage renal disease, and coronary artery disease. EVAR was also more often done in patients with a saccular aneurysm rather than fusiform. (93% vs. 70% in EAR and 42% in OIR; P=0.015). All-cause mortality rates at 1 year were not significantly different between the 3 groups. Survival at 5years did show a significant benefit of OIR over EVAR and EAR: OIR had an 8% mortality rate with EAR having a 53% rate and EVAR having the highest (72%) mortality rate at 5 years (P=0.03). Multivariable Cox regression analysis showed that EVAR (aHR 12.1, (95% CI 1.42 to 103.9), P=0.02) and EAR (aHR 15.1, (95% CI 1.59 to 143.3), P=0.0.02) had an increased 5-year mortality risk when compared to OIR. Repair of primary infected aortic aneurysm is associated with high complication and mortality rates regardless of the approach. In our studied sample, OIR offered an improved long-term survival without added benefits in terms of complication rates. In infected AAA, EVAR should be considered bridging stage between the urgent situation and eventual open repair.

Outcomes of Staged Repairs of Complex Endovascular Repairs of Thoracoabdominal Aortic Aneurysms

Endovascular treatment allows for the staging of thoracoabdominal aortic aneurysm repairs (eTAAAs) in an effort to decrease the risk of spinal cord ischemia (SCI), but data are limited. We studied all eTAAAs in the Vascular Quality Initiative from 2014 to 2021. Inverse probability weighting was used to compare perioperative and long-term outcomes of staged and single-stage repairs. Thoracoabdominal life-altering events (TALEs) are the composite endpoint consisting of death/stroke/permanent SCI/permanent dialysis. There were 3,258 total operations during the study period. In total, 841 cases (26%) were staged repairs, and 2,417 (74%) were completed in a single stage, but in the cohort of patients with extensive aneurysms, 44% were staged. Staging methods included thoracic endograft (78%), branch (23%), and iliac (5%). Staged repairs were more often employed by high-volume surgeons at high-volume centers; for larger, more extensive aneurysms, with higher rates of prior aortic surgery. After adjustment, staged repair and single-stage treatment were associated with similar odds of all perioperative outcomes and including mortality, TALE, acute kidney injury, stroke, dialysis, and SCI, as well as long-term survival. This was consistent in the subgroups of patients with extensive aneurysms undergoing elective procedures. Of note, first-stage thoracic endografts were associated with 2.6% mortality, 7.3% TALE, 1.5% dialysis, and 4.1% SCI, and 25% of patients did not undergo a second stage. First-stage procedures accounted for one-third of perioperative complications including half of the deaths in the staged cohort. Staged eTAAA repairs were associated with similar perioperative and long-term complications to single-stage treatments. However, first stage procedures are associated with significant morbidity and mortality, and one-quarter of patients never complete their repairs. These data demonstrate the necessity of evaluating the outcomes of all patients planned for staged procedures, not only those who make it to the final stage. More data are needed as to the optimal method of spinal cord protection for these challenging aneurysms.

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.

Is Marfan Syndrome Associated with Primary Structural Changes in the Left Atrium?

Marfan syndrome (MFS) is an autosomal-dominant multisystem connective tissue disorder that is based on mutations in the FBN1 gene and variably affects different organs, including the heart. In this study, we investigated cardiac function with a focus on the left atrium (LA) in a relatively large cohort of patients with MFS. After screening of 1165 patients that had been examined in our center between 2016 and 2020, 231 adult MFS patients with and without aortic operation were included in our study and compared to a healthy control group (n = 106). Cardiac function was assessed by transthoracic echocardiography and NT-proBNP was used as a secretory marker. Most (94.8%) of the patients received genetic testing. Left ventricular function was within normal ranges and not impaired. Interestingly, we found that LA size and secretory activity were increased in MFS patients, despite normal left ventricular filling pressures. This finding was even more pronounced in MFS patients with prior aortic surgery. A correlation between LA size or NT-proBNP levels and the type of pathogenic FBN1 variant could not be identified. Right ventricular function and right atrial size were increased only in MFS patients that had undergone aortic surgery. In conclusion, these findings suggest that MFS leads to structural changes in the LA that are not solely resulting from left ventricular dysfunction, but probably can be considered a primary pathology of MFS.

Using machine learning to predict outcomes following open abdominal aortic aneurysm repair

ObjectivePrediction of outcomes following open abdominal aortic aneurysm (AAA) repair remains challenging with a lack of widely used tools to guide perioperative management. We developed machine learning (ML) algorithms that predict outcomes following open AAA repair. MethodsThe Vascular Quality Initiative (VQI) database was used to identify patients who underwent elective open AAA repair between 2003 and 2023. Input features included 52 preoperative demographic/clinical variables. All available preoperative variables from VQI were used to maximize predictive performance. The primary outcome was in-hospital major adverse cardiovascular event (MACE; composite of myocardial infarction, stroke, or death). Secondary outcomes were individual components of the primary outcome, other in-hospital complications, and 1-year mortality and any reintervention. We split our data into training (70%) and test (30%) sets. Using 10-fold cross-validation, six ML models were trained using preoperative features (Extreme Gradient Boosting [XGBoost], random forest, Naïve Bayes classifier, support vector machine, artificial neural network, and logistic regression). The primary model evaluation metric was area under the receiver operating characteristic curve (AUROC). Model robustness was evaluated with calibration plot and Brier score. The top 10 predictive features in our final model were determined based on variable importance scores. Performance was assessed on subgroups based on age, sex, race, ethnicity, rurality, median area deprivation index, proximal clamp site, prior aortic surgery, and concomitant procedures. ResultsOverall, 12,027 patients were included. The primary outcome of in-hospital MACE occurred in 630 patients (5.2%). Compared with patients without a primary outcome, those who developed in-hospital MACE were older with more comorbidities, demonstrated poorer functional status, had more complex aneurysms, and were more likely to require concomitant procedures. Our best performing prediction model for in-hospital MACE was XGBoost, achieving an AUROC of 0.93 (95% confidence interval, 0.92-0.94). Comparatively, logistic regression had an AUROC of 0.71 (95% confidence interval, 0.70-0.73). For secondary outcomes, XGBoost achieved AUROCs between 0.84 and 0.94. The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.05. These findings highlight the excellent predictive performance of the XGBoost model. The top three predictive features in our algorithm for in-hospital MACE following open AAA repair were: (1) coronary artery disease; (2) American Society of Anesthesiologists classification; and (3) proximal clamp site. Model performance remained robust on all subgroup analyses. ConclusionsOpen AAA repair outcomes can be accurately predicted using preoperative data with our ML models, which perform better than logistic regression. Our automated algorithms can help guide risk-mitigation strategies for patients being considered for open AAA repair to improve outcomes.

Reoperative aortic root replacement for prosthetic aortic valve endocarditis: impact of aortic graft.

Existing aortic graft complicates the surgical management of prosthetic valve endocarditis (PVE); yet, its impact has not been well studied. We compared outcomes of patients with prior aortic valve replacement (AVR) versus aortic surgery plus AVR, who underwent reoperative aortic root replacement (ARR) for PVE of the aortic valve. All patients who underwent reoperative ARR for PVE between 2004 and 2021 from 2 aortic centres were included. Two groups were formed based on the presence/absence of aortic graft: prior aortic surgery (AO) and prior AVR (AV) alone. Inverse propensity treatment weighting matched the groups. The Kaplan-Meier method was used to analyse long-term survival, and Fine and Gray model was used to compare the cumulative incidence of reoperation. A total of 130 patients were included (AO n = 59; AV n = 71). After matching, AO patients had increased stroke incidence (12.4% vs 0.9%) and renal failure requiring dialysis (11.5% vs 2.5%). In-hospital mortality was comparable (21.5% AO and 18.6% AV). Survival over 5 years was 68.9% (56.6-83.8%) in AO and 62.7% (48.1-81.7%) in AV (P = 0.70). The cumulative incidence of reoperation was similar [AO 6.3% (0.0-13.2%) vs AV 6.1% (0.0-15.1%), P = 0.69]. Reoperative ARRs for prosthetic valve/graft endocarditis are high-risk procedures. AO patients had higher incidence of postoperative morbidity versus AV patients. For all patients surviving operative intervention, survival and reoperation rates over 5 years were comparable between groups.

Thoracic aorta diameters in Marfan patients: Intraindividual comparison of 3D modified relaxation-enhanced angiography without contrast and triggering (REACT) with transthoracic echocardiography

ObjectiveTo compare the measurement of aortic diameters using a novel flow-independent MR-Angiography (3D modified Relaxation-Enhanced Angiography without Contrast and Triggering (modified REACT)) and transthoracic echocardiography (TTE) in Marfan syndrome (MFS) patients. Material and methodsThis retrospective, single-center analysis included 46 examinations of 32 MFS patients (mean age 37.5 ± 11.3 years, 17 women, no prior aortic surgery) who received TTE and 3D modified REACT (ECG- and respiratory-triggering, Compressed SENSE factor 9 for acceleration of image acquisition) of the thoracic aorta. Aortic diameters (sinus of Valsalva (SV), sinotubular junction (STJ), and ascending aorta (AoA)) were independently measured by two cardiologists in TTE (leading-edge) and two radiologists in modified REACT (inner-edge, using multiplanar reconstruction). Intraclass correlation coefficient, Bland-Altman analyses, and Pearson's correlation (r) were used to assess agreement between observers and methods. ResultsInterobserver correlation at the SV, STJ, and AoA were excellent for both, TTE (ICC = 0.95–0.98) and modified REACT (ICC = 0.99–1.00). There was no significant difference between TTE and modified REACT for diameters measured at the SV (39.24 ± 3.24 mm vs. 39.63 ± 3.76 mm; p = 0.26; r = 0.78) and the STJ (35.16 ± 4.47 mm vs. 35.37 ± 4.74 mm; p = 0.552; r = 0.87). AoA diameters determined by TTE were larger than in modified REACT (34.29 ± 5.31 mm vs. 30.65 ± 5.64 mm; p < 0.01; r = 0.74). The mean scan time of modified REACT was 05:06 min ± 02:47 min, depending on the patient's breathing frequency and heart rate. ConclusionsBoth TTE and modified REACT showed a strong correlation for all aortic levels; however, at the AoA, diameters were larger using TTE, mostly due to the limited field of view of the latter with measurements being closer to the aortic valve. Given the excellent interobserver correlation and the strong agreement with TTE, modified REACT represents an attractive method to depict the thoracic aorta in MFS patients.

Greater Patient Travel Distance is Associated with Perioperative and One-Year Cost Increases After Complex Aortic Surgery

With increasing regionalization of complex aortic surgery within fewer US centers, patients may face increased travel burden when accessing aortic surgery. Longer travel distances have been associated with inferior outcomes after major surgery; however, the impacts of distance on reinterventions and costs have not been described. This study aims to assess the association between patient travel distance and longer-term outcomes including costs and reinterventions after complex aortic surgery. A retrospective review was conducted of all patients in the Vascular Implant Surveillance and Interventional Outcomes Network database undergoing complex endovascular aortic repair including internal iliac or visceral vessel involvement, complex thoracic endovascular aortic repair including Zone 0-2 proximal extent or branched devices, and complex open abdominal aortic aneurysm repair including suprarenal or higher clamp sites. Travel distance was stratified by Rural-Urban Commuting Area population-density category. Multinomial logistic regression models, negative-binomial models, and zero-inflated Poisson models were used to assess the association between travel distance and index procedural and comprehensive first-year costs, long-term imaging, and long-term reinterventions, respectively. Between 2011 and 2018, 8,782 patients underwent complex aortic surgery in the Vascular Implant Surveillance and Interventional Outcomes Network database, including 4,822 complex endovascular aortic repairs, 2,672 complex thoracic endovascular aortic repairs, and 1,288 complex open abdominal aortic aneurysm repairs. Median travel distance was 22.8 miles (interquartile range 8.6-54.8 miles, range 0-2,688.9 miles). Median age was 75years for all distance quintiles. Patients traveling farther were more likely to be female (26.8% in quintile 5 [Q5] vs. 19.9% in Q1, P<0.001) and to have had a prior aortic surgery (20.8% for Q5 vs. 5.9% for Q1, P<0.001). Patients traveling farther had higher index procedural costs, with adjusted odds ratio (OR) 2.34 (95% confidence interval [CI] 1.86-2.94, P<0.0001) of being in the highest cost tertile versus lowest for patients in Q5 vs. Q1. For patients with ≥ 1-year follow-up, those traveling farther had higher imaging costs, with adjusted Q5 OR 1.55 (95% CI 1.22-1.95, P=0.0002), and comprehensive first-year costs, with adjusted Q5 OR 2.06 (95% CI 1.57-2.70, P<0.0001). In contrast, patients traveling farther had similar numbers of reinterventions and imaging studies postoperatively. Patients traveling farther for complex aortic surgery have higher procedural costs, postoperative imaging costs, and comprehensive first-year costs. These patients should be targeted for increased care coordination for improved outcomes and healthcare system burden.

Factors Associated With Spinal Cord Ischemia After Thoracic, Abdominal, and Thoracoabdominal Endovascular Aortic Repairs

Spinal cord ischemia (SCI) is a challenging complication after endovascular aortic repair throughout the full extent of the aorta. However, data on factors associated with postoperative SCI development that are specific to the treatment extent are scarce. Therefore, we examined factors associated with SCI after thoracic endovascular aortic repair (TEVAR), complex endovascular aortic repair (cEVAR), and thoracoabdominal endovascular repairs (TAARs). All patients who underwent thoracic, abdominal, or TAAR from 2014 to 2019 were identified in the Vascular Quality Initiative linked with Medicare Claims. Procedures were classified into three subgroups based on repair extent: descending thoracic aortic repair (TEVAR), paravisceral segment of the abdominal aorta grouped as cEVAR, and TAAR. Logistic regression was used to identify factors associated with SCI within each group. Cox regression was used to evaluate the impact of SCI on 5-year survival. A total of 6591 patients were included (50% TEVAR, 42% cEVAR, and 8% TAAR). SCI incidence rates were 3.6%, 2.5%, and 11% for TEVAR, cEVAR, and TAAR, respectively. After TEVAR, preoperative renal dysfunction (odds ratio [OR]: 2.5, 95% confidence interval [CI]: 1.6-3.9; P < .001), ruptured presentation (OR: 3.9, 95% CI: 2.0-7.2; P < .001), and more extensive coverage (for each zone covered: OR: 1.5, 95% CI: 1.1-2.1; P = .008) were associated with higher odds of SCI. Left subclavian artery revascularization was associated with lower odds of SCI (OR: 0.48, 95% CI: 0.23-0.95; P = .041) (Table I). After cEVAR, patients with prior open (OR: 2.5, 95% CI: 1.1-5.1; P = .012) and endovascular (OR: 2.3, 95% CI: 1.1-4.8; P = .020) aortic surgery, longer operative times (for each hour: OR: 1.4, 95% CI: 1.2-1.5; P < .001), and more extensive coverage (for each zone covered: OR: 1.2, 95% CI: 1.0-1.4; P = .025) had higher odds of SCI (Table II). Notably, coverage extent and staged repair were not found to be significantly associated with SCI after TAAR (Table III). SCI was associated with higher 5-year mortality among all repairs (TEVAR: adjusted hazard ratio [aHR]: 2.1, CI: 1.6-2.9; P < .001; cEVAR: aHR: 3.4, CI: 2.4-4.7; P < .001; and TAAR: aHR: 2.1, CI: 1.3-3.2; P < .001). The extent of aortic zone coverage was associated with SCI after TEVAR and cEVAR, whereas prior aortic surgery was associated with SCI after cEVAR. Notably, left subclavian artery revascularization was associated with lower odds of SCI after TEVAR. In contrast to previous reports, staged repair was not associated with lower SCI risk after TAAR. Future studies should focus on procedure-specific risk factors to identify patients at higher risk of SCI and understand the optimal preventive strategy within specific procedures.Table ILogistic regression analysis for factors associated with SCI after TEVAR, cEVAR, or TAAACharacteristicTEVARcEVARTAAROR95% CIP valueOR95% CIP valueOR95% CIP valueAge1.000.98-1.0.901.00.99-1.0.111.00.95-1.0.9Gender (female)0.900.59-1.3.600.950.52-1.6.900.660.34-1.2.2White0.910.58-1.4.700.690.37-1.3.200.820.39-1.8.6Hypertension1.80.77-5.1.201.20.51-3.5.700.860.28-3.3.8Smoking history1.30.83-2.2.202.20.84-7.7.151.60.65-4.6.3Prior aortic surgery NoneRef.Ref.Ref.Ref.Ref.Ref.Ref.Ref.Ref. Open0.590.28-1.1.122.51.1-5.1.0121.30.61-2.8.30 Endovascular0.440.17-0.97.0672.31.1-4.8.0200.510.18-1.2.20 Both1.70.41-5.3.401.60.25-6.5.501.10.29-3.6.80COPD1.40.89-2.2.141.10.67-1.9.601.70.90-3.3.10Prior MI1.20.72-2.0.400.840.43-1.5.601.10.46-2.5.80Baseline eGFR <60 mL/min/1.73 m22.51.6-3.9<.0010.960.56-1.6.901.20.67-2.4.40Pathology TAARef.Ref.Ref.Ref.Ref.Ref.Ref.Ref.Ref. Accute dissection1.70.94-3.1.077–––––– CTBAD + PDA1.60.74-3.2.20–––––– Traumatic––––––––– PAU + IMH + (PAU + IMH)1.20.65-2.1.60–––––– Other–––1.40.33-4.6.501.10.50-2.6.70Presentation AsymptomaticRef.Ref.Ref.Ref.Ref.Ref.Ref.Ref.Ref. Symptomatic1.30.77-2.3.301.00.49-2.1.90.830.39-1.7.60 Rupture3.92.0-7.2<.0011.10.26-3.6.82.00.56-6.4.20Total procedure time, hours1.10.99-1.2.0671.41.2-1.5<.0011.00.95-1.2.20Estimated blood loss, 100 mL1.00.98-1.0.201.00.99-1.0.31.041.0-1.08.026Left subclavian artery treatment NoneRef.Ref.Ref.–––Ref.Ref.Ref. Occlusion0.830.43-1.5.50–––0.290.04-1.1.12 Revascularization0.480.23-0.95.041–––0.810.34-1.8.6Celiac involvement Infraceliac sealingRef.Ref.Ref.Ref.Ref.Ref. Supraceliac sealing1.60.90-3.1.110.790.38-1.6.5Hypogastric involvement None–––Ref.Ref.Ref.––– Hypogastric artery involvement–––0.710.14-2.6.6–––Staged aortic treatment––––––0.880.45-1.7.70Length of coverage (zones)1.51.1-2.1.0081.21.0-1.4.0251.050.89-1.2.6cEVAR, Complex endovascular aortic repair; CI, confidence interval; COPD, chronic obstructive pulmonary disease; CTBAD, complicated type B aortic dissection; eGFR, estimated glomerular filtration rate; IMH, intramural hematoma; MI, myocardial infarction; OR, odds ratio; PAU, penetrating aortic ulcer; PDA, patent ductus arteriosus; TAA, thoracic aortic aneurysm; TAAR, thoracoabdominal endovascular repair; TEVAR, thoracic endovascular aortic repair.Boldface P values represent statistical significance. Open table in a new tab

Outcomes Following Fenestrated Endovascular Aortic Repair for Failed Infrarenal Endovascular Aortic Repair Compared With Primary Fenestrated Endovascular Aortic Repair

Fenestrated endovascular aortic repair (FEVAR) is a potential treatment option in patients with failed EVAR due to proximal disease progression. However, studies evaluating the outcomes after FEVAR in patients with prior EVAR are limited to data from single-center and high-volume institutions. Therefore, we compared the outcomes after FEVAR in patients with prior EVAR vs without any prior aortic surgery (primary FEVAR). We identified patients undergoing elective FEVAR for complex abdominal aortic aneurysm in the Vascular Quality Initiative between 2014 and 2022 and included those who underwent no prior aortic surgery (n = 2362) or prior EVAR (n = 117). Perioperative outcomes and 5-year mortality were analyzed using logistic regression and Cox regression models. Sac changes were assessed based on differences in aneurysm sac diameter between the 1-year computed tomography scan and preoperative imaging and were categorized as regression (>5 mm decrease), stability (<5 mm change in size), and expansion (>5 mm increase) for analysis. We included 2362 primary FEVAR patients and 117 patients who underwent FEVAR after EVAR. The FEVAR after EVAR patients were older (76 [72-82] years vs 74 [68-79] years; P < .001), less frequently female (12% vs 23%; P = .004), had larger aneurysm diameters (68 [60-80] mm vs 58 [55-63] mm; P < .001), and more preoperative comorbidities. After EVAR patients, FEVAR patients were more likely to undergo repairs at high-volume centers performed by high-volume surgeons (P < .001). Furthermore, FEVAR after EVAR involved more proximal aortic zones with a higher number of branches and longer procedural time and radiation (all P < .05). Despite these differences, FEVAR after EVAR showed comparable perioperative outcomes relative to primary FEVAR (Table I). However, in the FEVAR, after EVAR group, 1-year sac regression rates were lower (24% vs 51%; P = .005), whereas sac expansion was more likely (39% vs 7.3%; P < .001) compared with the primary FEVAR group (Table II). At 2-year follow-up, FEVAR after EVAR was associated with similar mortality (26% vs 19%; hazard ratio: 1.4, 95% confidence interval: 0.84-2.2; P = .20) and reinterventions (14% vs 13%; hazard ratio: 1.04, 95% confidence interval: 0.36-3.0; P = .91) compared with primary FEVAR. FEVAR after EVAR has a similar risk of perioperative and 2-year mortality compared with primary FEVAR. However, the higher rate of sac expansion at 1 year in these patients raises significant concerns about the durability of these repairs. Therefore, patients undergoing FEVAR after EVAR may benefit from closer surveillance or even consideration for open conversion. Future studies should evaluate open conversion as an alternative to endovascular treatment for proximal failure of EVAR.Table IPerioperative outcomes after primary FEVAR vs FEVAR after prior EVARPrimary FEVAR (n = 2373)FEVAR after EVAR (n = 130)P valueFEAVR after EVAR vs primary FEVARP valueUnadjusted rates, %Adjusteda OR [95% CI]Perioperative death2.82.3.800.62 [0.13-2.2].50Any complication9.611.770.65 [0.29-1.4].30 Stroke0.60.66NANA AKI1214.700.75 [0.38-1.4].4 Postoperative dialysis1.72.3.740.73 [0.10-3.28].71 Bowel ischemia1.91.51.01.4 [0.18-6.2].71 Spinal cord ischemia1.53.1.270.85 [0.11-4.0].85 Leg ischemia1.92.3.740.68 [0.10-3.0].65 Pulmonary complications3.64.6.620.70 [0.21-2.0].52 Cardiac complications3.53.81.00.53 [0.14-1.6].30 Completion type 1A endoleak3.40.8.120.32 [0.02-1.73].29Reintervention during index hospitalization4.26.2.380.73 [0.48-1.1].12Unadjusted rates, %P valueAdjusteda HR [95% CI]P value2-year reintervention1314.201.04 [0.36-3.0].912-year mortality1926.701.4 [0.84-2.2].20AKI, Acute kidney injury; CI, confidence interval; EVAR, endovascular aortic repair; FEVAR, fenestrated EVAR; HR, hazard ratio; OR, odds ratio.aAdjusted for age, gender, diameter (>65 mm), hypertension, diabetes, prior myocardial infarction, prior chronic obstructive pulmonary disease, obesity, prior chronic kidney disease, anemia, proximal sealing zone, center volume, and physician volume. Open table in a new tab Table IISac dynamics at 1 year after primary FEVAR vs FEVAR after prior EVARPrimary FEVAR (n = 853), %FEVAR after EVAR (n = 33), %P valueSac regression, >5 mm5124.005Stable sac, <5 mm4232.67Sac expansion, >5 mm7.339<.001EVAR, Endovascular aortic repair; FEVAR, fenestrated EVAR.Boldface P value represents significance P < .05. Open table in a new tab

Valve-sparing root replacement versus composite valve graft root replacement: Analysis of more than 1500 patients from 2 aortic centers

ObjectivesThe long-term outcomes comparing valve-sparing root replacement, composite valve graft with bioprosthesis, and mechanical prosthesis have yet to be explored. We investigated the long-term survival and reintervention rates after 1 of 3 major aortic root replacements in patients with tricuspid aortic valves and patients with bicuspid aortic valves. MethodsA total of 1507 patients underwent valve-sparing root replacement (n = 700), composite valve graft with bioprosthesis (n = 703), or composite valve graft with mechanical prosthesis (n = 104) between 2004 and 2021 in 2 aortic centers, excluding those with dissection, endocarditis, stenosis, or prior aortic valve surgery. End points included mortality over time and cumulative incidence of aortic valve/proximal aorta reintervention. Multivariable Cox regression compared adjusted 12-year survival. Fine and Gray competing risk regression compared the risk and cumulative incidence of reintervention. Propensity score–matched subgroup analysis balanced the 2 major groups (composite valve graft with bioprosthesis and valve-sparing root replacement), and landmark analysis isolated outcomes beginning 4 years postoperatively. ResultsOn multivariable analysis, both composite valve graft with bioprosthesis (hazard ratio, 1.91, P = .001) and composite valve graft with mechanical prosthesis (hazard ratio, 2.62, P = .005) showed increased 12-year mortality risk versus valve-sparing root replacement. After propensity score matching, valve-sparing root replacement displayed improved 12-year survival versus composite valve graft with bioprosthesis (87.9% vs 78.8%, P = .033). Adjusted 12-year reintervention risk in patients receiving composite valve graft with bioprosthesis or composite valve graft with mechanical prosthesis versus valve-sparing root replacement was similar (composite valve graft with bioprosthesis subdistribution hazard ratio, 1.49, P = .170) (composite valve graft with mechanical prosthesis subdistribution hazard ratio, 0.28, P = .110), with a cumulative incidence of 7% in valve-sparing root replacement, 17% in composite valve graft with bioprosthesis, and 2% in composite valve graft with mechanical prosthesis (P = .420). Landmark analysis at 4 years showed an increased incidence of late reintervention in composite valve graft with bioprosthesis versus valve-sparing root replacement (P = .008). ConclusionsValve-sparing root replacement, composite valve graft with mechanical prosthesis, and composite valve graft with bioprosthesis demonstrated excellent 12-year survival, with valve-sparing root replacement associated with better survival. All 3 groups have low incidence of reintervention, with valve-sparing root replacement showing decreased late postoperative need for reintervention compared with composite valve graft with bioprosthesis.