Aortic Pathology Determines Midterm Outcome After Endovascular Repair of the Thoracic Aorta

Abstract

Given the spectrum of different pathologies that affect the descending thoracic aorta, it is important to define whether the outcome of TEVAR is pathology specific to refine procedural technique and endograft design. Careful analysis of long-term Background-Endovascular repair of the thoracic aorta has become an increasingly utilized therapy. Although the shortterm mortality advantage over open surgery is well documented, late mortality and the impact of presenting pathology on long-term outcomes remain poorly reported. Methods and Results-A database was built from 5 prospective studies and a single institutional series. Rates of perioperative adverse events were calculated, as were midterm death and reintervention rates. Multivariate analysis was performed with the use of logistic regression modeling. Kaplan-Meier survival curves were drawn for midterm outcomes. The database contained 1010 patients: 670 patients with thoracic aortic aneurysm, 195 with chronic type B aortic dissection, and 114 with acute type B aortic dissection. Lower elective mortality was observed in patients with chronic dissections (3%) compared with patients with aneurysms (5%). Multivariate analysis identified age, mode of admission, American Society of Anesthesiologists grade, and pathology as independent predictors of 30-day death (P < 0.05). In the midterm, the all-cause mortality rate was 8, 4.9, and 3.2 deaths per 100 patient-years for thoracic aortic aneurysm, acute type B aortic dissection, and chronic type B aortic dissection, respectively. The rates of aortic-related death were 0.6, 1.2, and 0.4 deaths per 100 patient-years for thoracic aortic aneurysm, acute type B aortic dissection, and chronic type B aortic dissection, respectively. Conclusions-This study indicated that the midterm outcomes of endovascular repair of the thoracic aorta are defined by presenting pathology, associated comorbidities, and mode of admission. Nonaortic mortality is high in the midterm for patients with thoracic aortic aneurysm, and managing modifiable risk factors appears vital. Endovascular repair of the thoracic aorta results in excellent midterm protection from aortic-related mortality, regardless of presenting pathology. (Circulation. 2013;127:24-32.)

Reintervention after thoracic endovascular aortic repair deserves more attention

“…Although TEVAR had the advantages of lower perioperative morbidity and mortality for type B aortic dissection, the advantages seemed to depend on a high rate of reintervention. Previous study reported that more than 20% of patients needed reintervention at 1-year after TEVAR (5) and the number reached up to 54% at 6-year (6).…”

The Value of Registries for Rare Diseases

“…3 Prospective registries in the endovascular management of other uncommon aortic diseases, including thoracic aortic dissection and aneurysm, have proven utility. 4,5 However, there are major drawbacks with such registries, including reporting bias, missing data, and selective loss to follow-up. Retrospective registries have additional limitations.…”

What Can We Learn From MOTHER?

“…7,8 Although the use of TEVR as a definitive treatment for either acute 9 or chronic 10 aortic dissection remains controversial, its use in emergent, complicated cases of acute DeBakey type III aortic dissection is generally considered acceptable and potentially lifesaving; in fact, in many programs, TEVR has become the treatment of choice for such cases. 11 Patterson and colleagues 12 are to be commended for reporting outcomes from one of the largest nonadministrative series of TEVRs (n=1010) in the current issue of From the 1010 patients in the series, the authors selected all those treated for aneurysm (n=670), chronic dissection (>2 weeks since onset; n=195), or acute dissection (≤2 weeks since onset; n=114), so the study cohort comprised 979 patients. In the analysis, patients were stratified according to their presenting pathology.…”

“…Additionally, such analysis is important in light of the disappointing long-term results of abdominal endovascular aortic repair, especially the enhanced risk of late rupture. 17 The study by Patterson et al 12 of the multicenter MOTHER database provides a valuable supplement to the 5-year pivotal trial outcomes for the Talent thoracic stent graft. 15 It seems reasonable to extrapolate the findings of this pivotal trial (n=195) to a much larger cohort of MOTHER patients (n=670).…”