Contemporary evaluation of mortality and stroke risk after thoracic endovascular aortic repair

Abstract

Objective Over the past decade, thoracic endovascular aortic repair (TEVAR) has increased as a treatment option for a variety of aortic pathologies. Despite this rise in the use of thoracic stent grafts, real-world outcomes from a robust, adjudicated, contemporary dataset have yet to be reported. Previous studies have shown peri-procedural mortality rates between 1.5%-9.5% and procedure-related stroke rates of 2.3%-8.2%. With advances in device engineering and increased physician experience, we hypothesized that the rates of these complications would be reduced in a more recent sample set. The purpose of this study was to determine current rates of mortality and stroke after TEVAR, identify risk factors that contribute to thirty-day mortality, and develop a simple scoring system that allows for risk stratification of patients undergoing TEVAR. Methods We examined the 30-day mortality rate following TEVAR using the 2013-2014 American College of Surgeons National Surgical Quality Improvement Program database. Patients undergoing TEVAR for all aortic pathology were identified using procedure codes. Bivariate analyses were performed to evaluate the association of pre-, intra- and post-operative variables with 30-day mortality, followed by multivariable logistic analysis using pre-operative variables only, with P<.10 as criteria for model entry. The predictive logistic model was internally validated by cross validation. Variables included in the multivariable model were used to develop a risk score. Results Eight hundred twenty-six patients were included. The thirty-day mortality and stroke rate were 7.63% (n=63) and 4.5% (n= 37), respectively. In regression analysis, mortality was independently associated with age ≥80 years (odds ratio [OR] 2.32, 95% confidence interval [CI] 1.25-4.31), emergency case (OR 2.61, 95% CI 1.39-4.90), ASA classification >3 (OR 2.89, 95% CI 1.34-6.24), transfusion >4 units in the 72 hours prior to surgery (OR 2.86, 95% CI 1.30-6.28), pre-operative creatinine ≥1.8 mg/dL (OR 2.07, 95% CI 1.05-4.08), and pre-operative white blood cell count ≥12 × 109/L (OR 2.65, 95% CI 1.41-4.96). Incorporating these factors, a six-point risk score was generated and demonstrated high predictability for overall thirty-day mortality. Conclusions Recent data from a national, retrospective dataset demonstrate that high perioperative mortality and stroke rates have persisted over the last decade. The risk score derived from this dataset is simple and convenient and serves as a prognostic tool in the pre-operative risk stratification of patients being evaluated for thoracic endovascular aortic repair.

Occlusion of the Celiac Artery during Endovascular Thoracoabdominal Aortic Aneurysm Repair Is associated with Increased Perioperative Morbidity and Mortality

“…Risk factors for mortality after TEVAR in literature include persistent type I or III endoleaks, emergent repair, postop MI or neurologic injury, 28 age >80, ASA class >3, elevated serum creatinine, >4 units transfused preop, and elevated white blood cell counts. 29 Symptomatic presentation was not found to be predictive of 30-day mortality in this cohort. To our knowledge, no other studies have identified CAO as an independent predictor of perioperative mortality.…”

Increasing Incidence of Thoracic Aortic Aneurysm Repair in Germany in the Endovascular Era: Secondary Data Analysis of the Nationwide German DRG Microdata

“…Endovascular repair was the treatment of choice for more than half of the patients presenting with an aneurysm located in the descending thoracic aorta for almost more than a decade, a trend that is clearly proven by the present data and reflects the recommendation of the ESVS guidelines for Management of Descending Thoracic Aorta Diseases. 1,32 Between 2005 and 2014, 93.6% of octogenarians were treated endovascularly. Interestingly, the Elixhauser comorbidity score was higher in the remaining 6.4% of elderly patients that received open aortic repair, most probably caused by comorbidities and complications that occurred post-operatively.…”

“…With increasing surgical experience as well as constantly evolving endovascular devices, implanting techniques, and imaging tools in a hybrid operating room, not only DTA aneurysms but also acute or chronic type B aortic dissections, aortic rupture, or aortic ulcers can be treated with minor trauma. A recently published study by Hu et al 32 identified age and emergency procedure as risk factors for increased 30 day mortality. In the current analysis, 35 who identified female sex as an independent predictor of peri-operative mortality following TEVAR for non-ruptured DTA aneurysm.…”

Methods and clinical outcomes of in situ fenestration for aortic arch revascularization during thoracic endovascular aortic repair

“…44 The stroke rate after TEVAR was reported to be 4.5% from a large national data set. 45 Although extracorporeal circulation was used in some articles, 20,25,29,33 majority of the procedure was performed without target vessel perfusion during ISF. This may cause cerebral ischemia.…”