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

Abstract

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.

Previous thoracic aortic repair is not associated with adverse outcomes after thoracic endovascular aortic repair

“…With the high rate of reintervention among a subset of patients who have undergone previous thoracic aortic repair and TEVAR frequently used as first-line treatment of most thoracic aortic pathologic entities, describing the perioperative outcomes and risks with TEVAR after previous thoracic aortic repair has become imperative for the contemporary management of aortic pathologic entities. 1,2 In the present patient cohort, the mortality after TEVAR without previous repair was comparable to the reported rates. In addition, this rate did not differ for those who had undergone TEVAR after previous aortic repair.…”

“…Thoracic endovascular aortic repair (TEVAR) has been increasingly used, and, in many cases, as first-line treatment of severe aortic pathologic entities such as dissections, aneurysms, and traumatic aortic injuries. [1][2][3][4] Because aortic disease can be chronic and progressive, a subset of patients exist who will require TEVAR after previous thoracic aortic repair. As many as 20% of patients who have undergone previous thoracic aortic repair will require reintervention, which could entail TEVAR.…”

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

“…28, 29 Similar to previous studies assessing the role of endovascular repair, we found that TEVAR was more commonly performed in urban teaching hospitals. 30–32 This was expected, as novel technologies and techniques such as TEVAR are typically introduced first to high volume academic centers.…”

“…17, 18 For rTAA patients, however, it is unknown whether the introduction TEVAR has broadened their treatment eligibility. 17 The purpose of this study was to assess national trends in the treatment of rTAA, focusing on the relative utilization and outcome of TEVAR, open repair, and nonoperative treatment.…”

Results from the Study to Assess Outcomes After Endovascular Repair for Multiple Thoracic Aortic Diseases (SUMMIT)

“…During the past two decades, thoracic endovascular aortic repair (TEVAR) has prevailed as the first-line therapy for most aortic diseases involving the descending thoracic aorta as recommended by both U.S. and European society guidelines. [1][2][3] Several meta-analyses, large registry studies, and large single-center studies have consistently demonstrated favorable outcomes after TEVAR compared with open surgical repair for the treatment of several descending thoracic diseases in the short term, [4][5][6][7][8] but many of these studies lack detailed information about the patients' pathologic and clinical characteristics as well as midterm or long-term results. Also, very few studies have examined the effect of presenting disease on TEVAR outcomes.…”