Emergency procedures on the descending thoracic aorta in the endovascular era

Mitchell, Marc; Rushton, Fred W.; Boland, A. Bradley; Byrd, Taylor C.; Baldwin, Zachary K.

doi:10.1016/j.jvs.2011.05.010

Cited by 44 publications

(23 citation statements)

References 19 publications

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“…Comparing these outcomes to historic results for open repair with mortality of up to 45%, 2, 6 Mitchell et al concluded that TEVAR has become the treatment of choice for acute thoracic aortic surgical emergencies. 13 However, comparative studies were unable to establish an absolute survival benefit of TEVAR over open repair. 4, 11, 14 Jonker et al evaluated morbidity and mortality after both operative approaches, and demonstrated that TEVAR was associated with a lower rate of perioperative adverse events in a multi-institutional study.…”

Section: Discussionmentioning

confidence: 99%

The impact of endovascular repair on management and outcome of ruptured thoracic aortic aneurysms

Ultee

Zettervall

Soden

et al. 2017

Journal of Vascular Surgery

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Introduction Endovascular repair (TEVAR) has become an alternative to open repair for the treatment of ruptured thoracic aortic aneurysms (rTAA). The aim of this study was to assess national trends in the utilization of TEVAR for the treatment of rTAA and determine its impact on perioperative outcomes. Methods Patients admitted with a ruptured thoracic aortic aneurysm between 1993 and 2012 were identified from the Nationwide Inpatient Sample (NIS). Patients were grouped in accordance with their treatment: TEVAR, open repair, or nonoperative treatment. The primary outcomes were treatment trends over time and in-hospital death. Secondary outcomes included perioperative complications and length of stay. Trend analyses were performed using the Cochran-Armitage test for trend, and adjusted mortality risks were established using multivariable logistic regression analysis. Results A total of 12,399 patients were included, with 1622 (13%) undergoing TEVAR, 2808 (23%) undergoing open repair, and 7969 (64%) not undergoing surgical treatment. TEVAR has been increasingly utilized from 2% of total admissions in 2003–2004 to 43% in 2011–2012 (P<.001). Concurrently, there was a decline in the proportion of patients undergoing open repair (29% to 12%, P<.001) and nonoperative treatment (69% to 45%, P<.001). The proportion of patients undergoing surgical repair has increased for all age groups since 1993–1994 (P<.001 for all), but was most pronounced among those aged 80 years with a 7.5 fold increase. After TEVAR was introduced, procedural mortality decreased from 36% in 2003–2004 to 27% in 2011–2012 (P<.001), while mortality among those undergoing nonoperative remained stable between 63% and 60% (P=.167). Overall mortality following rTAA admission decreased from 55% to 42% (P<.001). Since 2005, mortality for open repair was 33% and 22% for TEVAR (P<.001). In adjusted analysis, open repair was associated with a two-fold higher mortality than TEVAR (OR: 2.0, 95% CI: 1.7 – 2.5). Conclusion TEVAR has replaced open repair as primary surgical treatment for rTAA. The introduction of endovascular treatment appears to have broadened patient eligibility for surgical treatment, particularly among the elderly. Mortality following rTAA admission has declined since the introduction of TEVAR, which is the result of improved operative mortality, as well as the increased proportion of patients undergoing surgical repair.

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Section: Discussionmentioning

confidence: 99%

The impact of endovascular repair on management and outcome of ruptured thoracic aortic aneurysms

Ultee

Zettervall

Soden

et al. 2017

Journal of Vascular Surgery

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“…These studies consistently determined that TEVAR was associated with substantial decreases in perioperative morbidity and mortality compared to open repair. 7-9, 11, 16-19 A second AAST analysis was published in 2008, in which 65% of patients were treated using endovascular repair. 20 With an operative mortality of 7.2% and an incidence of paraplegia lower than 1%, perioperative outcomes following TEVAR were comparable to our study.…”

Section: Discussionmentioning

confidence: 99%

National trends in utilization and outcome of thoracic endovascular aortic repair for traumatic thoracic aortic injuries

Ultee

Soden

Chien

et al. 2016

Journal of Vascular Surgery

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Introduction Endovascular repair of traumatic thoracic aortic injuries (TTAI) is an alternative to conventional open surgical repair. Single institution studies have shown a survival benefit with TEVAR, but it is not clear if this is being realized nationally. The purpose of our study was to document trends in the increase in utilization of TEVAR and its impact on outcomes of TTAI nationally. Methods Patients admitted with a traumatic thoracic aortic injury between 2005 and 2011 were identified in the National Inpatient Sample (NIS). Patients were grouped by treatment into TEVAR, open repair, or nonoperative management groups. Primary outcomes were relative utilization over time and in-hospital mortality. Secondary outcomes included postoperative complications and length of stay. Multivariable logistic regression was performed to identify independent predictors of mortality. Results A total of 8384 patients were included, with 2492 (29.7%) undergoing TEVAR, 848 (10.1%) open repair, and 5044 (60.2%) managed nonoperatively. TEVAR has become the dominant treatment option for TTAI over the study period, starting at 6.5% of interventions in 2005 and accounting for 86.5% of interventions in 2011 (P<.001). Nonoperative management declined concurrently with the widespread of adoption TEVAR (79.8% to 53.7%, P<.001). In-hospital mortality following TEVAR decreased over the study period (33.3% in 2005 to 4.9% in 2011, P<.001), while an increase in mortality was observed for open repair (13.9% to 19.2%, P<.001). Procedural mortality (either TEVAR or open repair) decreased from 14.9% to 6.7% (P<.001), and mortality following any TTAI admission declined from 24.5% to 13.3% over the study period (P<.001). In addition to lower mortality, TEVAR was followed by fewer cardiac complications (4.1% vs. 8.5%), P<.001), respiratory complications (47.5% vs. 54.8%, P<.001), and shorter length of stay (18.4 vs. 20.2 days, P=.012) compared to open repair. In adjusted mortality analyses, open repair proved to be associated with twice the mortality risk compared to TEVAR (OR: 2.1, 95% CI: 1.6 – 2.7), while nonoperative management was associated with more than a four-fold increase in mortality (OR: 4.5, 95% CI: 3.8 – 5.3). Conclusions TEVAR is now the dominant surgical approach in TTAI with substantial perioperative morbidity and mortality benefits over open aortic repair. Overall mortality following admission for TTAI has declined, which is most likely the result of both the replacement of open repair by TEVAR, as well as the broadened eligibility for operative repair.

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“…in 1994 [4]. Thoracic endovascular aortic repair has become the most common procedure in the treatment of thoracic aorta aneurysms [1, 5]. …”

Section: Discussionmentioning

confidence: 99%

Hemoptysis as a first symptom of endoleak after thoracic endovascular aortic repair, which caused aortic rupture and required complex management

Synowiec¹,

Warot²,

Burchard³

et al. 2013

wiitm

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Thoracic endovascular aortic repair (TEVAR) has become the most common procedure in the treatment of thoracic aorta aneurysms. However, potential long-term complications of this technique could be life-threatening. Hemoptysis is a common symptom of lung tumor, especially cancer. On the other hand, hemoptysis can also be caused by bronchitis, tuberculosis, mycosis, and trauma. In this case report, we present a patient with hemoptysis and lung tumor suggesting lung cancer, which was a unique symptom of type IA endoleak after TEVAR and led to rupture of the thoracic aneurysm. It was decided to perform next an endovascular procedure due to the severe state of the patient. Next the thoracotomy was performed because drainage of the left pleural cavity was unsuccessful. In the last stage bronchoscopy was needed to remove the thrombus, which occluded the left main bronchi. Successful management has led to the patient's full recovery. Despite justified popularity of endovascular procedures in the treatment of thoracic aorta aneurysms, we should remember about potential long-term complications. Hemoptysis could be a unique symptom of the endoleak after TEVAR and treatment of such complications could be complex and demanding.

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Emergency procedures on the descending thoracic aorta in the endovascular era

Cited by 44 publications

References 19 publications

The impact of endovascular repair on management and outcome of ruptured thoracic aortic aneurysms

The impact of endovascular repair on management and outcome of ruptured thoracic aortic aneurysms

National trends in utilization and outcome of thoracic endovascular aortic repair for traumatic thoracic aortic injuries

Hemoptysis as a first symptom of endoleak after thoracic endovascular aortic repair, which caused aortic rupture and required complex management

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