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

Abstract

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.

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

“…Following the implementation of TEVAR, mortality decreased by 10% (from 36% to 27%). 33 The current analysis reveals that in hospital mortality after rDTA aneurysm repair shows a high variability over time, and ranges between 34.7% and 20.2%. In contrast, mortality rates for nrDTA aneurysm cases are bisected (9.4% in 2005 down to 4.2% in 2014).…”

Editor's Choice – Endovascular Repair Versus Surgical Repair for Japanese Patients With Ruptured Thoracic and Abdominal Aortic Aneurysms: A Nationwide Study

“…In addition, to separate ascending from descending thoracic aneurysms, patients who underwent cardiopulmonary bypass during the same hospital stay were excluded according to a previous study. 14 The following clinical data were extracted from the database: patients' unique identifiers; patients' backgrounds; comorbidities before admission; consciousness level on admission according to the Japan Coma Scale (JCS); treatments performed in the hospital, including operations, drugs, and additional treatments; length of hospital stay; total medical cost; and outcomes including in hospital death and ADL at discharge according to Barthel Index (BI). Diagnosis and comorbidities were primarily defined on the basis of the ICD-10 codes, but they were also checked to examine whether these were compatible with the code data.…”

Epidemiology of fatal ruptured aortic aneurysms in the United States (1999-2016)

“…During the past decades, the incidence of rAA is believed to have decreased because of primordial prevention (decreased prevalence of risk factors), primary prevention (population screening programs and elective repair), and improvement in surgical care for ruptured aneurysms. 4,5 A recent study has shown a decrease in ruptured abdominal aortic aneurysm (rAAA)-related hospitalizations from 21 to 16 per 100,000 persons in England and from 10 to 7 per 100,000 persons in the United States. 6 Despite that, aortic aneurysms and dissection were ranked as the 15th leading cause of death for people aged 65 years and older in the United States.…”