Commentary: Aortic repair in the Great White North—endovascular or open, eh?

Abstract

Open thoracoabdominal aortic aneurysm (TAAA) repair is among the most technically complex surgical procedures performed today. Even in high-volume centers of excellence, the incidence of mortality and morbidity remains daunting. As a result, the advent of endovascular repair for TAAA has been greeted with much enthusiasm and celebrated as a less-invasive treatment for a potentially fatal pathology. For high-risk patients, the propaganda has been nothing short of a panacea. In the last decade, endovascular repair of the descending thoracic aorta has largely superseded open repairs. 1 Such a dramatic shift in management strategy has ignited a firestorm of debate over which method should be used to treat TAAA. However, this revolutionary endovascular technology is a recent phenomenon-longterm outcomes of endovascular TAAA repair are simply not available.With their work, Rocha and colleagues 2 sought to determine the individual benefits of these 2 treatment strategies as performed in Ontario, Canada, using comprehensive provincial data. With a propensity-matched analysis for 241 patients undergoing open or endovascular repair of TAAA, they found that open procedures had a greater rate of in-hospital mortality and life-altering complications. These results were not unexpected, because the risks of open procedures are understood to be up-front, with traditional benefits perceptible long term. Their data also demonstrate that endovascular TAAA repairs had greater rates of reintervention compared with open procedures, thus affirming that an endovascular repair may not be as durable. This is not a benign finding-endovascular reintervention is not necessarily a free ride; studies suggest that subsequent interventions are associated with increased mortality rates. 3,4 Our own work has demonstrated that open TAAA repair is durable. 5

Subjective assessment underestimates surgical risk: On the potential benefits of cardiopulmonary exercise testing for open thoracoabdominal repair

“…This is particularly the case for increasing numbers of patients with TAAA who are considered for endovascular rather than open surgery 33 . It is likely that future treatment plans will incorporate both open and endovascular approaches for intervention and this may even be incorporated in a staged manner 34 …”