Improved midterm outcomes after endovascular repair of nontraumatic descending thoracic aortic rupture compared with open surgery.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has become first-line treatment for descending thoracic aortic rupture (DTAR), but its midterm and long-term outcomes remain undescribed. This study evaluated whether TEVAR would improve midterm outcomes of nontraumatic DTAR relative to open surgical repair (OSR). METHODS: Between December 1999 and October 2018, 118 patients with DTAR were treated with either OSR (n = 39) or TEVAR (n = 79) at a single center. Primary end points were 30-day and long-term all-cause mortalities. Secondary end points included stroke, permanent spinal cord ischemia (SCI), prolonged ventilation support or tracheostomy, permanent hemodialysis, and aortic reintervention. RESULTS: Thirty-day mortality was significantly lower with TEVAR (OSR, 38.5%; TEVAR, 16.5%; P = .01). Stroke (15.6% vs 3.8%; P = .03), permanent SCI (15.6% vs 2.5%; P = .02), prolonged ventilation (30.8% vs 8.9%; P = .002), and tracheostomy (12.8% vs 2.5%; P = .04) were significantly lower after TEVAR than OSR. Need for hemodialysis trended higher after OSR (12.8% vs 5.1%; P = .2). Mean follow ups were 1048 ± 1591 days for OSR group and 828 ± 1258 days for TEVAR. All-cause mortality at last follow-up was significantly lower after TEVAR than OSR (35.4% vs 66.7%; P = .001). Aortic reintervention was required more frequently within 30 days after TEVAR (15.2% vs 2.6%; P = .06). By multivariate analysis, TAAA was an independent predictor for mortality. CONCLUSIONS: TEVAR improves both early and midterm outcomes of DTAR relative to OSR. TAAA was a predictor of mortality. Endovascular approach to DTAR may provide the greatest chance at survival.

A Novel Technique for the Treatment of Type 2 Endoleak After Endovascular Aortic Repair: Sac Embolization with Balloon Occlusion of the Aorta (SEBOA).

PURPOSE: We presented a new method of sac embolization using n-butyl-cyanoacrylate (NBCA) with balloon occlusion of the aorta (SEBOA) that can facilitate decreasing flow rate of the involved branches with the goal of type 2 endoleak resolution after endovascular aortic repair (EVAR). TECHNIQUE: This technique is demonstrated in six patients who required type 2 endoleak treatment including previous technical failure. A transarterial approach was performed in four patients and transabdominal direct puncture in two. Technical success was defined as complete embolization of both involved branches and sac on postoperative CT. Sacography under balloon occlusion of the aorta demonstrated decreased flow rate of the all involved branches in all patients. SEBOA was performed using 25 or 33% of NBCA diluted with lipiodol. Technical success was obtained in 3 of 6 patients, and one major complication was observed with adhesion of NBCA to the microcatheter resulting in foreign body retention. CONCLUSION: SEBOA may help solve the difficulty of type 2 endoleak treatment after EVAR as decreased flow rate of the involved branches under balloon occlusion of the aorta was achieved in all patients. However, protocols regarding concentration of NBCA or using other embolic materials are needed to improve the success rate.