A 20-year experience with thoracic endovascular aortic repair.

BACKGROUND: Endovascular approaches (thoracic endovascular aortic repair) have revolutionized treatment of thoracic aortic disease. OBJECTIVE: We report our 20-year experience with this therapy. METHODS: Four hundred twenty patients (mean age = 69.0 years; 54% male) underwent thoracic endovascular aortic repair (1993-2013), predominantly for fusiform aneurysm (n = 144), saccular aneurysm (n = 94), acute (n = 64) or chronic (n = 36) dissection, or traumatic injury (n = 39). Rupture was present in 80 patients (19.1%). Most patients (78.3%) were at high risk for open repair. Mean aortic diameter was 5.5 cm. Extent of repair included arch in 218 patients, total descending aorta in 193 patients, and thoracoabdominal aorta in 35 patients. RESULTS: Thirty-day mortality occurred in 20 patients (4.8%). Neurologic events included stroke (5.0%) and spinal cord ischemia (permanent 1.7%, temporary 7.9%). Although dialysis was only required in 1.4% of the patients, 19% had renal failure by RIFLE (Risk, Injury, Failure) criteria. Endoleak occurred in 32.9% of the patients. Ten-year freedom from dissection, rupture, or need for reintervention in treated or adjacent aortic segments (ie, treatment failure) was 63.2%. Independent predictors included presentation with rupture, preexisting renal failure, or intervention on the arch aorta (all Ps < 0.03). Aortic pathology also independently predicted treatment failure (P = 0.026). The 15-year survival rate was 32.3%. Advancing age, presence of coronary artery disease, rupture, or postoperative renal failure (all Ps < 0.05), but not treatment failure (P = 0.926), independently predicted late mortality. CONCLUSIONS: Thoracic endovascular aortic repair can be performed with acceptable results in a high-risk population. The risk of treatment failure persists, underscoring the importance of continued long-term endograft surveillance, but this does not seem to impact late mortality.

Open arch reconstruction in the endovascular era: analysis of 721 patients over 17 years.

OBJECTIVE: Recent advancements in thoracic endovascular aortic repair, such as branched endografts or hybrid debranching/thoracic endovascular aortic repair, have extended the option of endoluminal therapy into the realm of the aortic arch. A contemporary assessment of open arch repair to provide long-term data for comparative analysis for these newer therapies is timely, warranted, and presented in this article. METHODS: Since the inception of our thoracic endovascular aortic repair program in 1993, 721 patients (mean age of 59.3 years, 68.9% were male) have undergone median sternotomy and open arch reconstruction with hypothermic circulatory arrest. Extended arch repair was performed in 42.7% with construction of bypasses to the innominate (296 patients), left carotid (216 patients), and subclavian (75 patients) arteries or elephant trunk procedures (42 patients). Concomitant aortic valve or aortic root replacement was required in 403 patients, and root reconstruction was required in 222 patients. Retrograde (641 patients) or antegrade (400 patients) cerebral perfusion was used for neuroprotection during hypothermic circulatory arrest. The operative procedure was urgent or emergency in 316 patients (43.8%) and included repair of type A dissection in 284 patients (39.3%). A total of 111 patients (15.4%) had undergone prior cardiac surgery. Primary outcomes in this study were early and late mortality. Follow-up was 100% complete (mean, 52.6 months). RESULTS: Thirty-day morbidity included death (36 patients [5%]), stroke (34 patients [4.7%]), and permanent dialysis (14 patients [1.9%]). Independent predictors of early mortality included advancing age, prolonged bypass times, and impaired ejection fraction (all P < .05). Actuarial survival at 10 years was 65%. Independent predictors of late mortality included advancing age, prolonged lower body circulatory arrest times, and increasing creatinine (all P < .05). By Kaplan-Meier analysis, 10-year survival was significantly reduced after operative procedures for type A dissection (non-type A 69.1% vs type A 58%, P = .003). Freedom from aortic reoperation (any segment) was 72.6% at 10 years. CONCLUSIONS: Open aortic arch repair can be accomplished with excellent early and late results. These outcomes provide objective data for comparison and suggest that newer endovascular therapies should be evaluated first in high-risk groups, such as those with advanced age or impaired renal function before broader application in all patients.

A comparison of open and endovascular descending thoracic aortic repair in patients older than 75 years of age.

BACKGROUND: Thoracic aortic endovascular repair (TEVAR) holds great promise in the elderly population. We conducted a concurrent comparison of TEVAR with open descending thoracic aneurysm repair (DTAR) in elderly patients to determine the more appropriate therapeutic option. METHODS: Since 1993, 93 patients aged 75 years and older have undergone open (n = 41) or endovascular (n = 52) descending aortic repair. Intervention indications included aneurysms, dissection, or traumatic injury. Mean maximum aortic diameter was 6.1 cm. Contained rupture was more frequent in TEVAR (p = 0.005); 52 needed arch repair, and 46 needed total descending repair. RESULTS: The mean age was 78.9 years (TEVAR, 80.6 vs DTAR, 76.9; p < 0.0001). The TEVAR patients had more significant comorbidities; 42 (80.8%) were prospectively identified as nonoperative candidates. Thirty-day mortality was higher in DTAR at 7 (17.1%) vs TEVAR at 3 (5.7%, p = 0.1). The composite end point of 30-day death, stroke, permanent paralysis, or dialysis requirement was similar (TEVAR, 9; DTAR, 10; p = 0.45). Median postoperative length of stay was shorter in TEVAR (6 days) vs DTAR (13 days; p = 0.003). Endoleaks were observed in 12. Actuarial survival at 48 months was similar (mean survival: TEVAR, 30.2 months vs DTAR, 33.7 months; p = 0.49). CONCLUSIONS: Despite more complex preoperative comorbidities, the TEVAR group had shorter hospitalization, a trend towards a reduction in early mortality, and similar late outcomes. This comparative analysis suggests that thoracic endovascular repair may be a more suitable therapeutic option in this complex elderly group.