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4.2.1.5 Gender Specic Differences intheManagement ofTAA
Gender-specic differences in 30-day mortality, length of hospital stay, and adverse
neurological events following repair of intact degenerative descending thoracic aortic aneurysms (TAAs), by either thoracic endovascular (TEVAR) or open repair
were assessed by Ulug et al. [10] in a systematic review and meta-analysis. For
TEVAR, six studies were eligible for the primary outcome of 30-day mortality,
including 1756 women and 2619 men. Pooled 30-day mortality was 5% in women
and 3% in men. No reasons for this difference were identied. Age did not account
for the difference. The hospital stay was longer in women; the two sexes did not
differ in the post-interventional stroke rate. Only one study was found for open
repair; it reported similar mortality in men and women.
4 Descending Thoracic Aortic Aneurysms (DTAA) and Thoracoabdominal Aortic…
4.2.2 Registry Data/Studies
4.2.2.1 Thoracic Aortic Aneurysm Growth
The UK National Health Service (NHS) ETTAA (Effective Treatments For Thoracic
Aortic Aneurysms) study recruited 886 patients with a descending thoracic aortic
aneurysm of ≥4cm in the arch or in the descending thoracic aorta [11]. The maximum aneurysm diameter was in the descending aorta in 725 (82%) patients, growing at 0.2 (0.17–0.24) cm per year. Aneurysms of ≥4cm in the arch increased by
0.07 (0.02 to 0.12) cm per year. During follow-up, 129 patients died (8.6% per
patient-year). Of these deaths, 64 (49.4%) were aneurysm-related. Of 307 patients
with aneurysms ≥6cm, 76 (23.1% per patient-year) died. In this group, 42 deaths
(12.7% per patient-year) were aneurysm-related deaths. The 1- and 3-year survival
rates were 92.4% (90.2–94.1) and 77.6% (73.4–81.2), respectively. Patients with
aneurysms of maximum diameter 4–6 cm had predicted 1-year mortality below
10%, which increases to 12.4% and 22.2% for 7cm and 8cm aneurysms, respectively. The authors concluded that large aneurysms should be treated with minimum
delay since 3-year probability of death jumps from just under 12% for “average”
patients with 5cm aneurysms to over 35% if the aneurysm increases to 7cm. These
increases will be greater for women and older patients. Similarly, the 3-year risk of
aneurysm-related death increases from approximately 5% for 5cm aneurysms to
over 20% for aneurysms of 7cm.
4.2.2.2 Long-Term Outcome After Endovascular andOpen
Repair ofTAA
To analyse the outcome after endovascular and open repair of descending thoracic
aortic aneurysms, Chiu etal. [12] performed a propensity score matching on patients
with intact descending thoracic aortic aneurysms who underwent TEVAR (n=2470)
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or open surgical repair (n=1235). The Medicare database between 1999 and 2010
with follow-up through 2014 was used. The median duration of follow-up in the
matched groups was 5.6 years for open surgical repair and 4.7 years for
TEVAR. Mortality at 180days was greater among open surgical repair patients,
23.8%, compared with TEVAR, 10.2%. The interaction between open surgical
repair and hospital volume was signicant: odds ratio for high-volume open surgical centers with respect to TEVAR: 1.97 (95% CI: 1.53 to 2.61) and for low volume
open surgical centers: 3.62 (95% CI: 2.88 to 4.51), p value for interaction=0.002.
The restricted mean survival time difference favored TEVAR at 9years, −209.2days
(95% CI: −298.7 to −119.7days; p<0.001) for open surgical repair. Risk of reintervention was lower for open surgical repair, hazard ratio: 0.40; p<0.001. In conclusion, open surgical repair was associated with increased odds of early
postoperative mortality but reduced late hazard of death. Despite the late advantage
of open repair, mean survival was superior for TEVAR.TEVAR should be considered the rst line for repair of intact descending thoracic aortic aneurysms in
Medicare beneciaries.
This conclusion was conrmed by the long-term results (median follow-up
102.8months) of a single centre treating 946 patients with thoracoabdominal aortic
aneurysms (TAAA, 79%) and descending thoracic aortic aneurysms (dTAA, 21%)
[13]. Acute patients undergoing open repair had signicantly higher 30-day mortality compared with endovascular (21.5% vs 4.4%; P<.01). However, there were no
differences in 30-day mortality between open and endovascular repair in the nonacute cases (3.7% vs 0%; P = .06). Endovascular repair was associated with
decreased perioperative mortality and signicantly increased long-term survival in
acute patients. Overall mortality rate at 10years was 51.0% (n=482), which was
signicantly higher than the expected 10-year mortality rate for the general agematched United States population (29.2%) (P<.01). Once patients undergo repair
of their aneurysm, aortic-related mortality remains low (aortic-related mortality was
2.1% over the study period).
From January 2000 to January 2010, 457 patients underwent open, and 596
patients underwent endovascular repair of descending TAA or TAAA at the
Cleveland Clinic [14]. Propensity score matching was performed, yielding 278
well-matched pairs. In matched patients, compared with endovascular stenting,
open repair achieved similar in-hospital death (8.3% vs 7.6%, P=.80) and occurrence of paralysis and stroke (3.6% vs 2.2%, P=.30), despite a longer postoperative
stay (median 11 vs 6days), more dialysis-dependent acute renal failure (8.6% vs
3.3%, P=.008), and prolonged ventilation (46% vs 6.3%, P< .0001). However,
open repair resulted in better 10-year survival than endovascular repair (52% vs
33%, P<.0001), and aortic reintervention was less frequent (4% vs 21%, P<.0001).
Despite a decrease in the rst postoperative year, average aneurysm size did not
recover to normal range after endovascular stenting. The authors concluded that
because of the perioperative safety prole and lower perioperative morbidity,
TEVAR is probably the method of choice in patients with TAA.However, in patients
with an unfavourable landing zone or young patients with low comorbidity, the
open approach should still be preferred due to better long-term outcomes.
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4 Descending Thoracic Aortic Aneurysms (DTAA) and Thoracoabdominal Aortic…
Midterm and long-term outcomes (median follow-up 2.1years) of TEVAR for
isolated descending thoracic aortic aneurysms (n=219), emphasizing postoperative
aortic remodeling and need for reintervention were reported by Tanious etal. [15].
30-day mortality was 10% for the cohort overall. Life-table analysis revealed an
overall survival of 78% at median follow-up. At 3 years, survival was 88%
(80%–93%) for those with aneurysm sac stability or regression, whereas it was 70%
(49%–84%) for those with aneurysm sac growth (P=.0402). Perioperative neurologic complications occurred in 16% of patients. Signicant predictors of sac
growth were endoleak (odds ratio [OR], 65; P < .001), preoperative carotidsubclavian bypass (OR, 8; P=.003), and graft oversizing <20% (OR, 15; P=.046).
Cox proportional hazards model showed that the only protective factor for mortality
was percentage oversizing, with every 1% of oversizing having a hazard ratio (HR)
of <.001 (P= .032). This was counterbalanced by the fact that patients with graft
oversizing >30% had an increased odds of mortality with HR >10 (P= .049). In
summary, the majority of patients (80%) experienced sac stability or regression
after TEVAR, which offers a clear survival advantage. Endoleaks are predictive of
sac growth, conferring increased mortality. Rigorous surveillance is necessary to
prevent future aortic events through reintervention.
4.2.2.3 Open TAA Repair inPatients withSplanchnic Occlusive Disease
The inuence of splanchnic occlusive disease (SOD) on outcomes after descending
thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) open
repair was reported by Gambardella etal. [16]. The occlusions were related to celiac
artery, superior and inferior mesenteric arteries, and renal arteries. SOD was absent
in 712 patients and present in 157 patients. Patients with SOD showed higher operative mortality (12.1% vs. 4.2%; p< 0.001), higher rates of SCI (6.4% vs. 2.2%;
p=0.004), tracheotomies (10.8% vs. 6.3%; p=0.047), dialysis (12.1% vs. 3.7%:
p < 0.001) and major complications (32.5% vs. 12.6%; p < 0.001). Survival of
patients with SOD was signicantly lower over 1 to 10years after surgery. Propensity
score matching led to 144 pairs each, with SOD signicantly associated with SCI
(6.9% vs 1.4%; P=.03) and MAE (32.6% vs 15%; P<.01). Ten-year survival was
reduced in those with SOD (31.5% vs 45.2%; P<.01). The results have shown that
SOD is a signicant predictor of SCI in patients undergoing open DTA/TAAA repair.
4.2.2.4 Open Surgical Repair inPatients withMarfan
andLoeys-Dietz Syndromes
A single centre retrospective study of 58 consecutive patients with Marfan syndromes (MS) (n=51) or Loeys-Dietz syndromes (LDS) was presented by Adam
etal. [17]. The median aortic diameter was 60 (55–74) mm. 21 patients underwent
open surgical replacement of the descending thoracic aortic and 37 patients underwent open thoracoabdominal aortic replacement. The 30-day mortality was 5.2%,
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permanent spinal cord injury was observed twice, permanent stroke once. The
median follow-up time was 81 months. The estimated 5-year survival rate was
85%±5%, and freedom from distal reintervention was 94%±3% at 5years. The
results demonstrate that descending thoracic and thoracoabdominal aortic replacement in patients with heritable thoracic aortic disease can be performed with low
perioperative morbidity and mortality, satisfactory long-term survival, and low
requirement for distal reintervention. The prerequisite for these excellent results is
the provision of care in specialized centres.
The largest European series to date of open thoracic and thoraco-abdominal aor-
tic repair in patients with connective tissue disease (CTD) was presented by
Keschenau etal. [18]. There were 72 procedures in 65 patients, 56 of whom had
Marfan syndrome. 64 procedures (89%) were elective procedures, 8 (11%) emergency procedures. The in- hospital mortality was 14% (n=9). Paraplegia and paraparesis were observed in 2% and 5%, respectively. Major complications were
revision surgery for bleeding or haematoma (n=20/65), sepsis (n=10/65), myocardial infarction/severe cardiac arrhythmia (n = 2/65), and stroke (n = 2/65).
Multivariate analysis identied an operating time of more than 7h (p=0.006) as an
independent predictor of increased mortality. Median follow-up was 42 months.
Freedom from re-intervention was 85%, 1year survival was 80%, and overall survival was 75%. Open TAA(A) repair is a durable therapy for patients with CTD.It
can be associated with relevant risks and should therefore be reserved for specialised centres. Staged procedures and thus reducing operating time, if applicable,
should be preferred.
4.2.2.5 Risk Factors forTEVAR
Naazie et al. [19] developed a risk calculator to predict 30-day mortality after
TEVAR for DTAA repair based on 2141 patients of the Vascular Quality Initiative
(VQI) database. In this series, 30-day mortality was 4.2% (90 patients). Clinically
relevant independent variables associated with 30-day mortality included age
75years or older (odds ratio 2.27), coronary artery disease (odds ratio 1.60), ASA
class IV/V (odds ratio 2.39), urgent vs elective procedure (odds ratio 3.47), emergent vs elective procedure (odds ratio 5.27), prior carotid revascularisation (odds
ratio 3.24), and proximal landing zone <3 (odds ratio 2.51). Internal validation demonstrated a bias-corrected area under the receiver operating characteristic curve of
0.73 (95% CI, 0.66–0.79) and a calibration slope of 1.00 with a corresponding inter-
cept of 0.00. This means a satisfactory discrimination between events and nonevents. The risk calculator should be used primarily in patient information and
consultation and is easy to use. It can be accessed at https://qxcalc.app.link/tevar.
Harris et al. [20] also developed a procedure-specic risk score for patients
undergoing elective TEVAR for DTAA.Their calculation was based on NSQIP data
from 2005 to 2016 (n=1784 patients). The post-interventional 30-day mortality in
this cohort was 4% for all patients. Signicant independent risk factors for major
adverse postoperative events included patient functional dependence (odds ratio
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4 Descending Thoracic Aortic Aneurysms (DTAA) and Thoracoabdominal Aortic…
2.9), prior pulmonary disease (OR 1.6), thoracoabdominal aneurysm extent (OR
2.2), need for iliac access (OR 2.1) and stent graft placement in zone I or II (OR
1.7). According to their respective beta coefcients, each variable was assigned a
single point. Based on total points, patients were stratied as low- (0 points), intermediate- (1 point), or high-risk (≥2 points), with stepwise increases in mortality
(0%, 4%, and 9%) and major complications (7%, 11%, and 23%) between strata.
While TEVAR is safe in low-risk patients, intermediate-risk patients warrant careful
discussion of the risks and benets of aortic intervention; under certain circumstances, high-risk patients may not benet.
Perioperative risk factors for TEVAR may include patient obesity. Naazie etal.
[21] reviewed data from 3423 patients in the VQI registry from 2014 to 2020 who
had been treated with TEVAR for DTAA or type B aortic dissection (TBAD). A
distinction was made between underweight (BMI <18.5 kg/m2), obesity (BMI
≥30kg/m2) and normal weight (BMI ≥18.5 to <30kg/m2). Underweight and nor-
mal weight patients did not differ in 30-day mortality. The adjusted hazard of 1-year
mortality was two-fold higher in underweight patients compared with normal
weight (hazard ratio, 2.15; P<.001), driven by a higher risk of mortality among
patients with thoracic aortic aneurysm (OR, 2.62; P<.001). In this study, obese
patients who underwent TEVAR for DTAA had comparable 30-day and 1-year mortality risk as normal weight individuals. Obese patients who underwent TEVAR for
TBAD demonstrated a 2.7-fold increase in the odds of 30-day mortality, but equivalent mortality risk as normal weight patients at 1year. TEVAR represents a safe
minimally invasive option for treatment of DTAA in obese patients.
Another risk factor might be an older age of the patient. Dakour-Aridi etal. [22]
compared the outcomes of TEVAR in octogenarians vs nonoctogenarians in the
treatment of thoracic aortic aneurysms and dissection. A total of 2042 patients were
identied in the VQI database, including 390 octogenarians (19.1%). Compared
with nonoctogenarians, octogenarians had higher percentages of females (49.5% vs
40.4%; P<.01) and white patients (75.9% vs 68.6%; P<.01) and were more likely
to present with thoracic aneurysms (86.2% vs 64.3%; P < .001). They also had
larger aortic diameters (maximum diameter, 60.3±15.8mm vs 53.4±17.4mm).
No association was observed between octogenarians and in-hospital mortality after
TEVAR for aneurysms (5.1% vs 3.3%; P = .33) or dissection (5.6% vs 4.9%;
P = .63). However, for thoracic aneurysm repair, octogenarians had 44% higher
adjusted odds of in-hospital complications (27.4% vs 20.7%; P= .03) compared
with their younger counterparts. Octogenarians also had increased hazard of 1-year
mortality. The ndings suggest that elderly patients should not be denied TEVAR
based on age if they are medically and anatomically t for this procedure.
In a retrospective cohort study based on the Society for Vascular Surgery Vascular
Quality Initiative (VQI) data, Deery etal. [23] identied 2574 patients who underwent TEVAR for an intact DTAA between 2011 and 2015. The goal of this study
was to evaluate the association between sex and morbidity and mortality after
TEVAR. 40% (n = 1038) of patients were women, and their aortic diameter was
smaller (5.8cm) compared to men (6.0cm) (p=0.02). However, after accounting
for body size, females had larger aortic size indices. Women were more likely than
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men to have COPD (33% vs. 28%; P=.01), more likely to be symptomatic (16%
vs. 10%) at presentation and subsequently were less likely to have an elective procedure (79% vs. 85%). Postoperatively, the rate of major adverse events was signicantly higher in women (7.6%) than in men (4.3%). Unadjusted mortality was
higher in female patients at 30days (5.4% vs 3.3%; P < .01) and 1year (12% vs
8.1%; P<.01). Even after adjusting for differences in age and comorbidities, female
patients had higher perioperative mortality and lower long-term survival after
TEVAR.These ndings, along with the rupture risk by sex, should be considered by
clinicians in determining the timing of intervention.
4.2.2.6 Ruptured Thoracic Aortic Aneurysms
Patel etal. [24] identied in the VQI registry 3039 patients with a thoracic aortic
aneurysm, 2806 (92%) had undergone repair for an intact aneurysm and 233 (8%)
had undergone repair for a ruptured aneurysm (complex aneurysms excluded).
Preoperative systolic blood pressure was less than 70mmHg in 40 (17%) patients,
70–100mmHg in 92 (40%) and>100mmHg in 82 (35%) patients. Compared to
patients without rupture, patients with rupture were signicantly less likely to have
a spinal drainage placed preoperatively (17% vs. 46%; p<0.001). EVAR for ruptured thoracic aortic aneurysms was associated with higher perioperative mortality
(rupture vs intact, 27% vs 4.6%; OR, 6.6; P < .001). Patients with rupture also
required more new dialysis (5.2% vs. 1.2%; p<0.001) and had more postoperative
paralysis (6.1% vs. 2.0%; p<0.001) and stroke (8.3% vs. 4.7%: p=0.016) compared to patients without rupture. Increasing age (per decade), increasing aortic
diameter, chronic kidney disease and previous stroke were associated with higher
odds of postoperative mortality. Five-year survival was lower after TEVAR for ruptured TAA than after TEVAR for intact TAA (50% vs. 76%; p<0.001). TEVAR for
ruptured thoracic aortic aneurysms resulted in increased perioperative mortality and
morbidity and lower 5-year survival compared with TEVAR for intact aneurysms.
Patients admitted with a ruptured TAA (rTAA) between 1993 and 2012 were
identied from the National Inpatient Sample by Ultee etal. [25]. 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 used 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). Overall mortality after rTAA admission decreased from 55% to
42% (P<.001). Since 2005, mortality for open repair was 33% and 22% for TEVAR
(P<.001). The study demonstrates that since its introduction, endovascular repair
has rapidly increased in use for the treatment of rTAA and is currently the primary
mode of treatment. Aside from replacing open repair, TEVAR has led to an increase
in the proportion of rTAA patients being treated surgically. TEVAR was associated
with favorable outcomes compared with open repair, despite TEVAR patients being
older and having more comorbidities. Because of the shift from open repair to
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Table 4.3 Perioperative outcomes of patients admitted with ruptured thoracic aortic aneurysm
between 2005 and 2012. National Inpatient Sample (NIS) database (according to Ultee etal. [25])
Variable
Death (%) 21.6 33.2 59.9 < .001
Cardiac complications (%) 16.6 31.2 17.0 < .001
Paraplegia (%) 3.7 5.6 0.6 .031
Stroke complication (%) 3.7 5.0 0.8 .165
Acute renal failure (%) 21.8 25.1 9.6 .072
Respiratory complications (%) 33.4 43.0 10.6 < .001
Wound dehiscence (%) 0.9 3.7 0.2 < .001
Postoperative infection (5) 0.6 3.8 0.2 < .001
Bleeding complication (%) 14.3 18.2 1.2 .015
Length of inpatient stay among those
who did not die during hospitalisation
(days)
Discharge to home (%) 27.2 21.1 9.3 .002
4 Descending Thoracic Aortic Aneurysms (DTAA) and Thoracoabdominal Aortic…
TEVAR
n=1549
13.7 17.2 5.2 < .001
Open repair
n=765
Nonoperative
n=2511
P OR vs.
TEVAR
TEVAR and the shift from nonoperative treatment to TEVAR, overall mortality
after rTAA admission declined during the study period. The perioperative outcomes
after TEVAR and open repair, and the outcome of non-operative treatment of ruptured TAA for the years 2005 to 2012 are shown in Table4.3.
4.2.3 Specic Issues withTAAA
4.2.3.1 Staged Hybrid Repair ofExtent II TAAA
Hawkins etal. [26] compared morbidity, mortality, cost, and value for staged hybrid
vs open repair of extent II TAAAs. Of 113 consecutive patients who underwent
Crawford extent II TAAA repair, 25 (22.1%) had a staged hybrid approach with
TEVAR of the proximal aorta, followed by open surgical repair of the distal aorta
with a median of 129days between procedures. The hybrid group had shorter operative time (255 vs 306min; P=.01), shorter postoperative length of stay (10.1 vs
13.3days; P=.02), and reduced blood loss (1300 vs 2600mL; P=.01) at the time
of open operation. Despite higher rates of acute kidney injury in the hybrid group
(76.0% vs 51.1%; P=.03), there was no difference in renal failure (8.0% vs 4.5%;
P=.84). The incidence of MAEs was lower in the staged hybrid group (20.0% vs
48.9%; P=.01), without a difference in hospital mortality (4.0% vs 3.4%; P=.89).
The two-stage was more expensive but resulted in lower combined risk of spinal
cord ischemia, renal failure, or death than standard one-stage open repair. The
authors suggested two-stage hybrid repair of type II thoracoabdominal aneurysms
over standard one-stage open repair.
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4.2.3.2 F/BEVAR Procedures forExtensive TAAAs
299 fenestrated/branched endovascular (F/BEVAR) procedures were performed for
87 extensive TAAAs (29%) and 212 nonextensive TAAAs (71%) by Diamond etal.
[27]. Between the two groups, no perioperative differences were observed in myocardial infarction, stroke, acute kidney injury, dialysis, target artery occlusion,
access site complication, or type I or III endoleak (P>.05 for all). The incidence of
perioperative paraparesis was greater in the extensive TAAA group (8.1% vs 0.5%;
P=.001). However, the incidence of long-term paralysis was equivalent (2.3% vs
0.5%; P=.20), with nearly all patients with paraparesis regaining ambulatory func-
tion. On Kaplan-Meier analysis, there were no signicant differences between the
two groups in 1-year mortality (15.1% vs. 11.4%) and 3-year survival (61.9% vs.
62.5%). Unlike open TAAA repair, the F/BEVAR outcomes were similar for exten-
sive and nonextensive TAAAs. The differences in perioperative paraparesis, branch
instability, and type I or III endoleak likely resulted from the increasing length of
aortic coverage and number of target arteries involved.
The SPIDER-graft for TAAA hybrid repair [28] was developed to minimize
operative trauma, to avoid extracorporeal circulation (ECC) with related increased
perioperative risk factors, to further reduce ischemic time of visceral organs, and to
reduce the risk of spinal cord ischemia (SCI). The SPIDER-graft uses a combined
endovascular thoracic and open abdominal aortic approach for TAAA repair in a
single-stage operation, thereby avoiding the need for thoracotomy and ECC while
enabling reimplantation of visceral, renal, and lumbar arteries. This device consists
of a proximal stent graft for transabdominal retrograde delivery to the descending
aorta combined with a distal six branched abdominal device for open abdominal
aortic repair. The device has limitations, as it is not applicable to all thoracoabdominal aortic aneurysms (TAAA) and type B acute aortic dissections (TBAD).
Its indication is seen predominantly in patients with type III and IV TAAA, especially in patients with unsuitable anatomy for total endovascular repair [29].
4.2.3.3 Open TAAA Repair inHigh Volume Centres
From October 1986 to December 2014, 3309 consecutive open TAAA repairs were
performed on Baylor College of Medicine (Crawford extent I n=914; extent II
n=1066; extent III n=660; extent IV n=669) [30]. 723 (21.8%) were urgent or
emergency procedures. Repairs were performed to treat degenerative aneurysm
(64.2%) or aortic dissection (35.8%). There were 249 operative deaths (7.5%).
Permanent paraplegia and paraparesis occurred after 97 (2.9%) and 81 (2.4%)
repairs, respectively. Of 189 patients (5.7%) with permanent renal failure, 107 died
in the hospital. Permanent stroke was relatively uncommon (n= 74; 2.2%). The
aortic diameter was approximately 1 cm larger in emergency/urgent procedures
(6.9cm) than in elective procedures (6.1cm there). There were 1864 late deaths,
with an estimated postoperative survival of 83.5% at 1year, 63.6% at 5years, 36.8%
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at 10years and 18.3% at 15years. Patients who underwent surgery for dissection
showed a signicant survival advantage over patients with degenerative TAAA.
descending thoracic (DTAA) or TAAA in 1795 patients. Mean age was 64.2±13.8,
and 702 (37%) were women. Of 1896 operations, 646 (34.1%) were DTAA, 316
(16.7%) TAAA extent I, 310 (16.4%) TAAA extent II, 187 (9.9%) TAAA extent III,
348 (18.4%) TAAA extent IV, and 112 (5.9%) TAAA extent V.Adjunct [cerebrospinal uid drainage (CSFD) + distal aortic perfusion (DAP)] was used in 78.4%.
Postoperative stroke was 95/1896 (5%). Early mortality was 302/1896 (15.9%).
Moreover, renal failure requiring dialysis occurred in 316 (16.6%). For nonemergent procedures among patients with poor baseline renal function (lowest GFR
quartile <48.3), early mortality was 27% (96/356) versus 5.2% (21/405) among
those with good baseline renal function (highest GFR quartile >95.3), P<0.0001.
For emergent procedures among patients with poor baseline renal function (lowest
GFR quartile <48.3), early mortality was 51.9% (28/54) versus 16.7% (4/24) among
those with good baseline renal function (highest GFR quartile >95.3), P=0.003.
Moreover, for patients with normal renal function, nonemergent, and nonextent II or
III TAAA, the early mortality was 3.7%. Overall survival for the entire cohort at 5,
10, 15, and 20years was 57.7%, 42.9%, 34.8%, and 31.6%, respectively.
4 Descending Thoracic Aortic Aneurysms (DTAA) and Thoracoabdominal Aortic…
Between January 1991 and December 2014, Estrera et al. [31] repaired 1896
4.3 Conclusions forClinical Practice
1. In patients who can undergo both methods (open repair, OR or TEVAR), TEVAR
is recommended as the preferred approach for elective repair of aneurysms of the
descending thoracic aorta. The same applies to ruptured TAA.
2. There are no such clear recommendations for the repair of TAAA. OR and
TEVAR are considered equivalent in patients with low and moderate surgical
risk. Nevertheless, hybrid techniques and the use of (F/B) endografts make open
repair increasingly rare.
3. CSF drainage plays a role in the prevention of paraplegia and paraparesis and
should be considered for open repair of extensive TAAs. The same applies to
TEVAR patients with planned extensive thoracic aortic coverage (> 200mm) or
previous abdominal aortic aneurysm (AAA) repair.
4. The experience of the surgeon and the centre is crucial for the results of TAAA
repair—this applies to both OR and TEVAR—which makes it absolutely necessary to concentrate care of these patients in high volume centres.
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4.4 Perioperative Management
4.4.1 Diagnostic Methods inDescending Thoracic
Aortic Disease
4.4.1.1 Guideline Recommendations
European Society for Vascular Surgery (ESVS) Clinical Practice Guidelines [1]
• All patients with clinical suspicion of thoracic aortic disease and abnormal chest
radiograph should undergo computed tomographic angiography for diagnosis
conrmation. (Class I recommendation/Level of evidence C).
• Multidetector computed tomography angiography from thoracic inlet to common femoral arteries should be considered as the rst line diagnostic modality
for descending thoracic aortic pathology. (Class IIa recommendation/Level of
evidence C).
• For the diagnosis of descending thoracic aortic disease, transoesophageal echocardiography should be considered as a second line imaging when CT is unavailable, contraindicated or inconclusive. (Class IIa recommendation/Evidence
level C).
• For patients at increased risk of contrast induced nephropathy, volume expansion
with either isotonic sodium chloride or sodium bicarbonate solutions should be
considered before contrast administration. (Class IIa recommendation/Level of
evidence C).
4.4.2 Preoperative Statin Therapy andSurvival After TEVAR
Allar etal. [32] investigated the association between statin use and survival after
thoracic endovascular aortic repair (TEVAR). Of 6266 patients who had undergone
TEVAR and met the inclusion criteria, 3331 (53%) patients had been taking a statin
preoperatively (VQI database). After propensity score matching, 1875 patients were
in each cohort. Preoperative statin use was associated with lower rates of any perioperative complication (16.7% vs. 19.6%; p=.022) and also with 5-year mortality
(18.8% vs. 24.5%; p=0.001). When stratied by urgency of procedure, preoperative statin use was associated with lower 5-year mortality after elective TEVAR
(14.9% vs. 22.4%), but not after urgent or emergent TEVAR (27.4% vs. 29.1%;
p=0.37). When stratied by pathology, preoperative statin use was associated with
signicantly lower 5-year mortality for patients with aneurysms but not for patients
with dissections. (Although the mortality was also lower for patients with dissection
and “other” pathology). A signicant increase in statin use was observed in patients
with elective TEVAR between 2014 to 2019, from 56% to 64% (p = 0.007). The
data suggest that all patients with known thoracic aortic pathology should receive
statin therapy unless contraindications for the drug are present. For patients
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