Impact of Secondary Aortic Interventions After Thoracic Endovascular Aortic Repair on Long-Term Survival

Mahmoud Alhussaini; George J Arnaoutakis; Salvatore T Scali; Kristina A Giles; Javairiah Fatima; Martin Back; Dean Arnaoutakis; Eric I Jeng; Tomas D Martin; Dan Neal; Thomas M Beaver

doi:10.1016/j.athoracsur.2019.10.015

Impact of Secondary Aortic Interventions After Thoracic Endovascular Aortic Repair on Long-Term Survival

Ann Thorac Surg. 2020 Jul;110(1):27-38. doi: 10.1016/j.athoracsur.2019.10.015. Epub 2019 Nov 27.

Affiliations

¹ Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida; Cardiothoracic Surgery Department, Assiut University, Assiut, Egypt.
² Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida.
³ Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Florida.
⁴ Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida; Department of Surgery, University of Florida, Gainesville, Florida.
⁵ Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida. Electronic address: thomas.beaver@surgery.ufl.edu.

PMID: 31785293
DOI: 10.1016/j.athoracsur.2019.10.015

Abstract

Background: The indications for and technology surrounding thoracic endovascular aortic repair (TEVAR) have undergone significant evolution with increasing adoption. The purpose of this report is to evaluate pathology-specific incidence, timing, and types of secondary aortic intervention (SAI) after TEVAR and their impact on survival.

Methods: A single-center retrospective review was made of all TEVAR and SAI performed from 2004 to 2018. Kaplan-Meier and multivariable logistic regression were used to estimate freedom from SAI and survival, and to identify SAI predictors.

Results: Of 1037 patients (mean age 65.4 ± 15.1 years), 155 (14.9%) underwent 212 SAIs (median 5 months; interquartile range, 1.5 to 18) with 37 (3.6%) requiring more than one SAI. The primary aortic pathology at index TEVAR significantly (P = .0001) affected the incidence of SAI: chronic dissection, 26.5%; postsurgical anastomotic pseudoaneurysm, 19.4%; degenerative aneurysm, 15.3%; and acute dissection, 11.2%. The most common indications for SAI were endoleaks (44.8%), disease progression or remote aortic procedure (23.1%), and persistent false lumen flow (9.9%). After exclusion of 30-day mortality events, patients who did not undergo a SAI had better survival compared with patients having SAI: no SAI 1 year 88.8% ± 1.1%, 5 years 75.2% ± 1.7%, and 10 years, 66.5% ± 2.3%; SAI 1 year 91.7% ± 2.4%, 5 years 61.9% ± 4.9%, and 10 years 33.5% ± 8.4% (log rank P = .004).

Conclusions: Secondary aortic intervention after TEVAR is not uncommon, particularly among patients with chronic dissection pathology. Patients surviving their index hospitalization who undergo SAI have worse long-term survival. The varying incidence of SAI by indication identifies the need for pathology-specified patient selection, surveillance strategies after TEVAR, and better device design that addresses the limitations of TEVAR, particularly in dealing with dissection-related indications.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Aged
Aged, 80 and over
Anastomotic Leak / epidemiology
Anastomotic Leak / surgery
Aneurysm, False / epidemiology
Aneurysm, False / surgery
Aorta, Thoracic / surgery*
Aortic Aneurysm, Thoracic / surgery*
Aortic Dissection / surgery*
Blood Vessel Prosthesis Implantation* / adverse effects
Comorbidity
Disease-Free Survival
Endovascular Procedures*
Female
Follow-Up Studies
Humans
Kaplan-Meier Estimate
Male
Middle Aged
Postoperative Complications / epidemiology
Postoperative Complications / surgery
Registries
Reoperation
Retrospective Studies
Risk Factors
Treatment Outcome