Long-term comparison of thoracic endovascular aortic repair (TEVAR) to open surgery for the treatment of thoracic aortic aneurysms
Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, 3400 Spruce St, 6th Floor Silverstein Pavilion, Philadelphia, PA 19096, USA. The Journal of thoracic and cardiovascular surgery
(Impact Factor: 4.17).
09/2012; 144(3):604-9; discussion 609-11. DOI: 10.1016/j.jtcvs.2012.05.049
Thoracic endovascular aortic repair (TEVAR) has become a widely established treatment for a variety of thoracic aortic pathologic diseases despite limited long-term data to support its use. We compared the long-term outcomes of TEVAR with the 3 commercially available stents grafts for thoracic aortic aneurysms to results in control subjects undergoing open surgery.
Demographic, clinical radiographic parameters were collected prospectively on patients enrolled in trials assessing the Gore TAG (55), Medtronic Talent (36) and Cook TX2 (15) devices. Outcomes were compared with 45 contemporaneous open controls. Detailed clinical and radiographic information was available for analysis. Standard univariate, survival, and regression methods were used.
During the study period (1995-2007) 106 patients were enrolled in TEVAR trials and there were 45 open controls. TEVAR patients were older and had significantly more comorbidities including diabetes and renal failure. TEVAR patients had 2.3 ± 1.3 devices implanted. Mortality (2.6% TEVAR, 6.7% open; P = .1), paralysis/paraparesis (3.9% TEVAR, 7.1% open; P = .2), and prolonged intubation more than 24 hours (9% TEVAR, 24% open; P = .02) tended to be more common in the open controls. Overall survival at 10 years was similar between groups (log rank P = .5). Multivariate predictors of late mortality included age, chronic obstructive pulmonary disease, diabetes, and chronic renal failure. Use of TEVAR versus open surgery did not influence mortality (hazard ratio, 0.9 95% confidence interval, 0.4-1.6). Over 5 years of radiographic follow-up in the TEVAR group, mean aortic diameter decreased from 61 to 55 mm. Freedom from reintervention on the treated segment was 85% in TEVAR patients at 10 years.
TEVAR is a safe and effective procedure to treat thoracic aortic aneurysms with improved perioperative and similar long-term results as open thoracic aortic repair. TEVAR-treated aneurysm diameters initially decrease and then stabilize over time.
Available from: Radhouane Bousselmi
- "Periprocedural mortality is seen in 2.6% of the patients. It is mostly related to thoracic aorta rupture. "
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ABSTRACT: Thoracic endovascular aortic repair (TEVAR) is still associated with complications which include mortality in 7.3% of cases. In this report, we describe the case of a man with a pseudoaneurysm of the aortic isthmus that was scheduled to undergo endovascular repair. During the procedure, the patient had a sudden cardiac arrest due to a compressive hemopericardium caused by perforation of the ascending aorta. The diagnosis was not clear and was made by transthoracic echocardiography after five minutes of resuscitation. In spite of the evacuation of the hemopericardium and suture of the perforation, the patient died. The diagnosis would have been easier and faster if the patient had been monitored continuously by transesophageal echocardiography during the procedure.
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ABSTRACT: Aortic injuries represent a rare but life-threatening complication of spinal surgery. Perforation of the aorta due to pedicle screw penetration or misplacement can lead to immediate bleeding with hemodynamic instability or to pseudoaneurysm development with delayed risk of rupture, which can occur weeks to months later. Recently, thoracic endovascular aortic repair (TEVAR) in aortic trauma has contributed to a reduction of both mortality and morbidity. The literature on this subject is reviewed.
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Paraparesis and paraplegia after thoracic endovascular aneurysm repair (TEVAR) is a greatly feared complication. Multiple case series report this risk up to 13% with no, or inconsistent, application of interventions to enhance and protect spinal cord perfusion. In this study, we report our single-institution experience of TEVAR, using the same proactive spinal cord ischemia protection protocol we use for open repair.
Endovascular thoracic aortic interventions were performed for both on-label (aneurysm) and off-label (trauma, other) indications. Aortic area covered was recorded as a fraction from the subclavian to celiac origins and reported as a percentage. If debranching was required, measurements were taken from the most distal arch vessel left intact. Intraoperative imaging and postoperative computed tomographic angiogram were used in calculating aortic percent coverage. Outcomes were recorded in a clinical database and analyzed retrospectively. The spinal cord ischemia protection included routine spinal drainage (spinal fluid pressure <10 mm Hg), endorphin receptor blockade (naloxone infusion), moderate intraoperative hypothermia (<35°C), hypotension avoidance (mean arterial pressure >90 mm Hg), and optimizing cardiac function.
From 2005 to 2012, 94 consecutive TEVARs were studied. Indications were thoracic aneurysm (n = 48), plaque rupture with or without dissection (n = 23), trauma (n = 15), and other (n = 8). Forty-nine percent were acute, average age was 68.5 years, 60% (n = 56) were male, and the mean follow-up was 12 months. Mean length of aortic coverage was 161 mm, correlating to 59.4% aortic coverage. One patient had delayed paralysis (1.1%; observed/expected ratio, 0.12) and recovered enough to ambulate easily without assistance. Other complications included wound (7.5%), stroke (4.3%), myocardial infarct (4.3%), and renal failure (1.1%).
Proactive spinal cord protective protocols appear to reduce the incidence of spinal ischemia after TEVAR compared with historical series. This study would suggest that active, as opposed to reactive, approaches to spinal ischemia portend a better long-term outcome. Multimodal protection is essential, especially if long segment coverage is planned.
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