Clinical Outcomes of Celiac Artery Coverage vs Preservation During Thoracic Endovascular Aortic Repair.

ABSTRACT

BACKGROUND: Adequate proximal and distal seal zones are necessary for successful Thoracic Endovascular Aortic Repair (TEVAR). Often, the achievement of an adequate distal seal zone requires celiac artery (CA) coverage by endograft with or without preservation of CA blood flow. The outcomes of CA coverage without its flow preservation were studied only in small case series. This study aims to determine the difference in outcomes between CA coverage with vs without preservation of CA blood flow during TEVAR using a multi-institutional national database. METHODS: Vascular Quality Initiative (VQI) was reviewed for all TEVAR patients distally landing in Zone 6. The cohort was divided into TEVAR with vs without CA flow preservation. Demographic, clinical, and perioperative characteristics, as well as post-operative mortality, morbidities, and complications, were compared between the groups. Univariate and multivariate regression analyses were performed. RESULTS: Out of 25,549 reviewed patients, 772 had a distal landing in zone 6, 212 of which (27.5%) had TEVAR without CA flow preservation, whereas 560 (72.5%) underwent TEVAR with CA flow preservation. Indications for TEVAR were aneurysm in 431 (55.8%), dissection in 247 (32.0%), or other in 94 (12.2%) cases. Patients who underwent TEVAR without CA flow preservation had statistically significantly higher rates of 30-day mortality (11.3% vs 5.9%, p=0.010), 30-day disease/treatment-related mortality (8.0% vs 4.3%, p=0.039), as well as a tendency of increased intestinal ischemia requiring intervention (1.9% vs 0.5%, p=0.077). After adjusting for potential confounders, CA coverage without flow preservation was associated with more than a two-fold increase in the overall 30-day mortality (OR 2.83, 95%CI 1.35-5.92, p=0.006) and 30-day disease/treatment-related mortality (OR 2.72, 95%CI 1.11-6.72, p=0.029). In a sub-group analysis based on disease pathology, these results persisted only in the aneurysm group (30-day mortality (OR 2.36, 95%CI 1.01-5.48, p=0.047), 30-day disease/treatment-related mortality (OR 2.88, 95%CI 1.08-7.67, p=0.034)), whereas there was no significant association between CA flow preservation status and the endpoints in the dissection subgroup (30-day mortality (OR 1.16, 95%CI 0.22-6.05, p=0.856), 30-day disease/treatment-related mortality (OR 0.90, 95%CI 0.16-5.19, p=0.911)). CONCLUSIONS: CA coverage during TEVAR without preservation of its blood flow is associated with significantly higher mortality in patients with aortic aneurysm, but not dissection. In patients with aortic aneurysm CA flow should be preserved during TEVAR whenever feasible, whereas in patients with dissection, it may be safe to cover CA without preservation of its flow. Prospective studies should be done to confirm these findings and compare the open vs endovascular revascularization techniques on outcomes.