Spinal cord ischemia after elective stent-graft repair of the thoracic aorta

Open repair of extensive thoracoabdominal and thoracic aneurysm: a preliminary single-center experience with femorofemoral distal aortic perfusion with oxygenator and without cerebrospinal fluid drainage

Thoracoabdominal aortic aneurysms (TAAA) and extensive thoracic descending aortic aneurysms (TDA) are not accessible through standard endovascular treatment. Fenestrated and branched endograft technology was developed rapidly without widespread application. The aim of this study was to review our open repair (OR) experience of TAAA and TDA. A total of 28 patients who underwent elective OR of TAAA or TDA between January 2001 and January 2009 were analyzed retrospectively. The mean age of the patients was 65.5 years (three women). The anatomic locations of the aneurysms were as follows: six in thoracic descending aorta and 22 in thoracoabdominal aorta (14 TAAA I, two TAAA II, six TAAA III). TDA (40 patients) available for ordinary endovascular treatment and TAAA IV (35 patients) were excluded from this study. To focus on spinal cord vascularization, 25 patients were submitted for angiography. Three patients suffering from back pain required quick treatment and were excluded from angiographic investigations. Angiography procedures were contributive in 23 patients (92%). Surgical repairs were driven through left thoraco-phreno-laparotomy, with the adjunct of distal aortic perfusion (femorofemoral bypass) including the use of an oxygenator and sequential aortic cross-clamping. Cerebrospinal fluid drainage was not used in this experience. The 30-day mortality rate was 14.3% (four of 28 patients): one multiorgan failure and three pulmonary sepsis. An immediate postoperative paraplegia occurred, affecting a patient with TDA who was previously submitted for infrarenal aorta replacement, despite angiographic identification and revascularization of intercostal artery destined to spinal artery. The 1-year survival rate was 82.1% (23 of 28 patients). In the preliminary experience of this study, OR of extensive TAAA and TDA with distal aortic perfusion and an oxygenator without use of cerebrospinal fluid drainage was associated with a significant perioperative mortality rate (14.2%), a reasonable rate of paraplegia (3%), and 1-year survival rate of 82.1%.

[Spinal cord protection during open and endovascular surgery in thoracic and thoracoabdominal aorta diseases]

In recent decades great advances have been made in surgical procedures for treating thoracic and thoracoabdominal aorta defects. Associated mortality and morbidity rates have dropped considerably, mainly in major reference centers, but nonetheless continue to be significant. The need for new strategies to reduce mortality and morbidity has made endovascular approaches an attractive alternative for high-risk surgical patients. The most feared complications of these procedures include paraparesis and paraplegia, which have devastating consequences on patients' quality of life. We provide an updated review of the pathophysiology of spinal cord ischemia in open and endovascular surgery, as well as perioperative measures designed to protect the spinal cord in both types of procedure.

How to manage the left subclavian artery during endovascular stenting for thoracic aortic dissection? An assessment of the evidence

BACKGROUND

Despite the publication of recent guidelines for management of the left subclavian artery (LSA) during endovascular stenting procedures of the thoracic aorta, specific management for those presenting with dissection remains unclear. This systematic review attempts to address this issue.

METHODS

Systematic assessment of the published data on thoracic aorta dissection was performed identifying 46 studies, which incorporated 1,275 patients. Primary outcomes included the prevalence of left arm ischemia, stroke, spinal cord ischemia, endoleak, stent migration, and mortality. Outcomes were compared between patients with and without LSA coverage and revascularization incorporating factors such as the number of stents used, length of aorta covered, urgency of intervention, and type of dissection (acute or chronic). Statistical pooling techniques, χ(2) tests, and Fisher's exact testing were used for group comparisons.

RESULTS

As compared with other outcomes, LSA coverage without revascularization in the presence of aortic dissection is much more likely to be complicated by left arm ischemia (prevalence increased from 0.0% to 4.0% [p = 0.021]), stroke (prevalence increased from 1.4% to 9.0% [p = 0.009]), and endoleak (prevalence increased from 4.0% to 29.3% [p = 0.001]). However, revascularization was not shown to reverse these effects. Longer aortic coverage (≥ 150 mm) was associated with an increased prevalence of spinal cord ischemia (from 1.3% to 12.5% [p = 0.011]) and mortality (from 1.3% to 15.6% [p = 0.003]).

CONCLUSION

In patients undergoing endovascular stenting for thoracic aortic dissection, in cases where LSA coverage is necessary, revascularization should be considered before the procedure to avoid complications such as left arm ischemia, stroke, and endoleak, and where feasible, an appropriate preoperative assessment should be carried out.

Nontumor lesions of spinal cord and spine

Nontumor lesions of the spinal cord and spine include developmental disorders, cystic tumor-like lesions, vascular disorders, infective diseases, demyelinating diseases, degenerative diseases, metabolic and toxic disorders, and spinal cord injury. In addition, diseases of the spine and extradural spaces secondarily cause spinal cord injury. Aside from tumors, these include developmental abnormalities, inflammatory diseases, nontumor space-occupying lesions, and tumor-like lesions such as lipomas, vascular malformations, and cysts. Awareness is required of hemostatic agents used during surgery and subsequently presenting as space-occupying lesions, which have to be differentiated from recurrent lesions. On the therapeutic front, stem cell transplantation into spinal cord for treatment of neurodegenerative disorders, spinal cord injury, and multiple sclerosis is a challenging prospect.

Intrathecal lactate concentration and spinal cord injury in thoracoabdominal aortic surgery

OBJECTIVE

The aim of this study was to evaluate the role of lactate as an early predictor of spinal cord injury during thoracoabdominal aortic aneurysm repair.

DESIGN

Observational study.

SETTING

University hospital.

PARTICIPANTS

Sixteen consecutive patients (10 men and 6 women) scheduled to undergo thoracoabdominal aortic aneurysm repair were enrolled in the study. All patients were affected by atherosclerotic aneurysmal pathology.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

During surgery, the authors simultaneously withdrew samples of cerebrospinal fluid and arterial blood to evaluate pO(2), pCO(2), pH, and lactate concentration. Samples were collected at 5 fixed times during and after surgery: T1 (before aortic cross-clamping), T2 (15 minutes after clamping), T3 (just before unclamping), T4 (end of surgery), and T5 (4 hours after the end of surgery). Lactate levels in cerebrospinal fluid rose consistently during aortic cross-clamping (T1 = 1.89 mmol/L, T2 = 2.21 mmol/L, T3 = 2.88 mmol/L, T4 = 3.655 mmol/L, and T5 = 3.16 mmol/L). Lactate concentrations in the cerebrospinal fluid were significantly higher in the 4 patients who developed neurologic injury, even at T1 (before surgery), than in those who did not end in spinal cord injury with the 4 highest values belonging to the 4 patients who later developed spinal cord injury.

CONCLUSIONS

This study has the potential to elucidate the time course of early lactate level elevation during thoracoabdominal aortic aneurysm repair and its clinical use in predicting the development of postoperative spinal cord injury.

Excessively high systemic blood pressure in the early phase of reperfusion exacerbates early-onset paraplegia in rabbit aortic surgery

OBJECTIVE

We have demonstrated that therapeutic augmentation of systemic blood pressure during spinal cord ischemia plays an important role in minimizing spinal cord injury in both experimental and clinical aortic surgery. However, there remain concerns that excessively high blood pressure during spinal cord reperfusion may aggravate the reperfusion injury. The purpose of this study is to investigate the effect of high blood pressure during spinal cord reperfusion on postoperative neurologic outcomes after aortic surgery in rabbits.

METHODS

Experiments were performed using a rabbit spinal cord ischemia-reperfusion model in 2 randomly divided groups: (1) In the HR group, the mean blood pressure was maintained at a high level (121 +/- 1.3 mm Hg) during reperfusion with intravenously administered phenylephrine; and (2) in the CR group, the mean blood pressure was not medically controlled (75 +/- 9.1 mm Hg) during reperfusion. Neurologic and histologic assessments and evaluation of early reperfusion injury were performed.

RESULTS

In the HR group, slow and incomplete recovery of transcranial motor-evoked potentials (P = .02) and low neurologic scores (P < .005) were observed during spinal cord reperfusion compared with the CR group. At 48 hours of reperfusion, there were significantly fewer viable neuron cells, more apoptosis, and more perivascular edema with gray matter vacuolation in the HR group (P < .001 for each). At 3 hours, myeloperoxidase activity (P = .0021), vascular permeability (P = .0012), and superoxide generation (P < .0001) were significantly increased in the HR group.

CONCLUSION

Excessively high blood pressure in the early phase of spinal cord reperfusion increased reperfusion injury in the spinal cord, leading to exacerbation of early-onset paraplegia. Avoidance of spinal cord reperfusion with high blood pressure may be one management strategy in thoracoabdominal aortic surgery.

Endovascular treatment of aortoesophageal and aortobronchial fistulae

BACKGROUND

Even when promptly recognized and treated, aortoesophageal (AEF) and aortobronchial (ABF) fistulae are highly lethal conditions. Open surgical repair also carries a high risk of mortality and morbidity. Several alternative strategies have been recently reported in the literature including thoracic endovascular aortic repair (TEVAR). However, relatively little is known about results of TEVAR for AEF and ABF due to their rarity and the lack of large surveys.

METHODS

A voluntary national survey was conducted among Italian universities and hospital centers with an endovascular program. Questionnaires were distributed by e-mail to participating centers and aimed to evaluate the results of endovascular repair of established AEF or ABF.

RESULTS

Seventeen centers agreed to participate and provided data on their patients. Between 1998 and 2008, a total of 1138 patients were treated with TEVAR. In 25 patients (2.2%), the indication to treatment was an AEF and/or an ABF. In 10 of these cases (40%), an associated open surgical procedure was also performed. Thirty-day mortality rate of AEF/ABF endovascular repair was 28% (7 cases). No cases of paraplegia or stroke were observed. Mean follow-up was 22.6 months (range, 1-62). Actuarial survival at 2 years was 55%. Among the 18 initial survivors, five patients (28%) underwent reintervention due to late TEVAR failure.

CONCLUSIONS

Stent grafting for AEF and ABF represents a viable option in emergent and urgent settings. However, further esophageal or bronchial repair is necessary in most cases. Despite less invasive attempts, mortality associated with these conditions remains very high.

Aorto-oesophageal and aortobronchial fistulae following thoracic endovascular aortic repair: a national survey

OBJECTIVE

We evaluated the incidence of aorto-oesophageal (AEF) and aortobronchial (ABF) fistulae after thoracic endovascular aortic repair (TEVAR), and investigated their clinical features, determinants, therapeutic options and results.

METHODS

We conducted a voluntary national survey among Italian universities and hospital centres with a thoracic endovascular programme.

RESULTS

Thirty-nine centres were contacted, and 17 participated. Of the patients who underwent TEVAR between 1998 and 2008, 19/1113 (1.7%) developed AEF/ABF. Among indications to TEVAR, aortic pseudo-aneurysm was associated with the development of late AEF/ABF (P = 0.009). Further, emergent and complicated procedures resulted in increased risk of AEF/ABF (P = 0.008 and P < 0.001, respectively). Eight patients were treated conservatively, all of whom died within 30 days. Eleven patients underwent AEF/ABF surgical treatment, with a perioperative mortality of 64% (7/11). At a mean follow-up of 17.7 +/- 12.5 months, overall survival was 16% (3/19).

CONCLUSIONS

The incidence of AEF and ABF following TEVAR is not negligible, and is comparable to that following open repair. This finding warrants an ad hoc long-term follow-up after TEVAR, particularly in patients submitted to emergent and complicated procedures. Both surgical and endovascular treatment of AEF/ABF are associated with high mortality. However, conservative treatment does not appear to be a viable option.

Identifying Paraplegia Risk Associated with Thoracic Endografting

Endografting, like open surgical repair of the thoracic aorta, can be complicated by paraplegia. We reviewed our thoracic endografting experience regarding the incidence and treatment of spinal cord neurologic events. Between February 2000 and July 2008, 346 patients underwent endoluminal grafting of the descending thoracic aorta. Indications for intervention included atherosclerotic aneurysms (45.9%), acute and chronic dissections (31.5%), miscellaneous lesions (13.6%), and penetrating aortic ulcers (8.9%). Ten women and 4 men (4.0%), with a mean age of 71.3 years, developed either paraparesis (1.7%) or paraplegia (2.3%). Nine (64.3%) of these patients had an aneurysm, 4 (28.6%) had acute or chronic type B aortic dissection, and 1 (7.1%) had a penetrating aortic ulcer; 3 (21.4%) of them had previously undergone open abdominal aortic aneurysm repair, and 13 (92.9%) required coverage of more than 20 cm of the aorta. Cerebrospinal fluid drainage was instituted in 7/8 paraplegic patients. Eight (57.1%) of the 14 patients recovered fully, 2 (14.3%) experienced partial recovery, and 4 (28.6%) had significant neurological deficits. Paraplegia following thoracic endografting appears to be associated with female sex, longsegment coverage of the thoracic aorta, and aneurysmal disease.

Advances in imaging of the spinal cord vascular supply and its relationship with paraplegia after aortic interventions. A review

INTRODUCTION

Preoperative knowledge of the spinal cord (SC) vasculature could be useful for stratifying and decreasing the risk of perioperative paraplegia after thoracic and thoraco-abdominal aortic surgery. Recent advances in magnetic resonance (MR) and computed tomography (CT) angiography and post-processing techniques have improved this knowledge.

METHODS

A search of MEDLINE/Pubmed and SCOPUS databases identified 1414 pertinent abstracts; 123 full-length manuscripts were screened to identify relevant studies with acceptable design and patient numbers. Forty-three were selected.

RESULTS

SC circulation was studied in 1196 patients to detect the great radicular artery: 522 by MR-angiography and 674 by CT angiography. Detection rates were 67-100% (mean 80.8%) with MR-angiography being 18-100% (mean 72%) with CT angiography. The side and level of the great radicular artery were consistent between the methods. Several authors tried to use the imaging results to guide clinical management.

CONCLUSIONS

Non-invasive imaging of the SC blood supply allows preoperative definition of the vasculature in many, but not all, cases. The impact of these findings on clinical management is potentially beneficial but still uncertain. Further improvements in image acquisition and post-processing techniques are needed. Future studies need to be large enough to compensate for inter-individual variability in SC vasculature in health and disease; however, even a partial reduction of paraplegia rate offers a formidable motivation for further research in this area.

Endovascular repair in the thoracic and abdominal aorta: no increased risk of spinal cord ischemia when both territories are treated

PURPOSE

To evaluate the morbidity associated with thoracic and abdominal aortic repair using endovascular exclusion alone or combined endovascular and open repair.

METHODS

Between January 1998 and February 2007, 49 patients (36 men; mean age 70 years) underwent treatment for thoracic and abdominal aorta disease with descending thoracic aortic (DTA) stent-graft and abdominal aortic repair. Thirty-nine patients with coexisting thoracic and abdominal pathologies were classified with multilevel aortic disease (MLAD), whereas 10 patients presented with thoracoabdominal aneurysm. Patients were separated into 3 groups: 1: thoracic stent-grafts and open abdominal repair (n = 18), group 2: thoracic and abdominal stent-grafts (n = 21), and group 3: thoracic stent-grafts with visceral artery debranching (n = 10). Prior carotid-subclavian bypass was performed in 3 (6%) patients with a dominant left vertebral artery.

RESULTS

Stent-graft deployment was technically successful in all cases. Eight (16%) patients underwent emergent thoracic stent-graft placement. In 9 (18%) patients, the left subclavian artery was covered. No incidence of spinal cord ischemia was observed. The 30-day mortality was 4%, and overall mortality was 6% over a mean 33-month follow-up. The endoleak rate was 6% (1 type I, 1 type II, and 1 type III).

CONCLUSION

Conventional or endovascular abdominal open repair in combination with DTA stent-grafting is feasible and a safe alternative to traditional open repair. Management of MLAD did not show increased incidence of spinal cord ischemia and was associated with fewer complications and deaths than simultaneous or staged open thoracic and abdominal repairs.

Endovascular stenting of thoracic aortic aneurysm

In 2005, the findings of the multicenter Gore Tag study led to United States Food and Drug Administration approval for endovascular repair of thoracic aortic aneurysms (TEVAR). TEVAR provides a therapeutic option for patients who have thoracic aortic aneurysm and for the treatment of type B aortic dissection with malperfusion. Spinal cord ischemia and stroke are recognized neurologic complications of TEVAR. Identification of high-risk patients combined with targeted anesthetic and perioperative management may decrease the risk of neurologic complications after TEVAR.

Chronic kidney disease classification stratifies mortality risk after elective stent graft repair of the thoracic aorta

OBJECTIVE

Risk factors for perioperative and late mortality after thoracic endovascular aortic repair (TEVAR) remain ill-defined. In this study, we examined the prognostic significance of chronic kidney disease (CKD), a well-known predictor of death after thoracic aorta open repair, employing a stratification based on CKD stages derived from glomerular filtration rate (GFR) values.

METHODS

A prospective database was evaluated for 179 consecutive patients electively submitted to TEVAR between 1999 and 2007. Preoperative GFR was estimated by using the Cockcroft-Gault equation. Patient groups were stratified into four quartiles by baseline serum creatinine (SC) and GFR values, with quartile I being the lowest, and quartile IV the highest, and into the five CKD stages in reverse order (I GFR >or= 90 ml/min/1.73 m(2); II 60-89; III 30-59; IV 15-29; V < 15). Prognostic significance of preoperative GFR values and CKD stages were investigated by means of univariate and multivariate analyses, and the Kaplan-Meier log-rank method.

RESULTS

A primary technical success was achieved in 166 of 179 patients (92.7%), and an initial clinical success in 158 (88.3%). Thirty-day mortality was 5% (nine cases). Paraplegia or paraparesis were observed in 11 (6.1%) patients, and completely resolved in six cases after cerebrospinal fluid drainage. Preoperative GFR quartiles and CKD stages were significant predictors of 30-day mortality (P = .004 and P < .0001 respectively), whereas SC quartiles did not affect the outcome (P = .12). In particular, GFR quartile I (<60 ml/min/1.73 m(2)) was associated with a ten-fold greater risk of perioperative death compared with the other three quartiles (Odds Ratio 11.4, 95% Confidence Interval 2.3-57.0, P = .003). Midterm survival was 88.8% (159 of 179) at a mean follow-up of 35.6 +/- 23.7 months. Actuarial survival at 60 months was 57.8%, 81.1%, 92.3%, and 100% for GFR quartiles I to IV respectively (P < .0001), and 0.0%, 66.7%, 59.2%, 88.6%, and 100% (P < .0001) for CKD stage V to I respectively. At univariate analyses, age (P = .019), preoperative SC quartiles (P = .001), GFR quartiles (P = .0002), and CKD stages (P < .0001) were all predictive of mid-term mortality. At multivariate Cox proportional hazards regression analysis, only CKD stages remained independently associated with the outcome (P = .008).

CONCLUSIONS

GFR is an accurate prognostic predictor in patients submitted to TEVAR. Also, perioperative and midterm mortality directly correlate with the severity of CKD stages, allowing a risk stratification model to be employed both for risk-adjusted preoperative evaluation, and to establish accurate matching criteria for comparative studies.

Contemporary Analysis of Descending Thoracic and Thoracoabdominal Aneurysm Repair

Background— Endovascular repair of thoracic aneurysm has demonstrated low risks of mortality and spinal cord ischemia (SCI), but few large series have been published on endovascular thoracoabdominal aneurysm repair, and reports suffer from a lack of accurate comparison with similar open surgical procedures.

Methods and Results— A consecutive cohort of patients with thoracic and thoracoabdominal aneurysms treated electively with endovascular repair (ER) or surgical repair (SR) techniques between 2001 and 2006 were analyzed. The association between repair technique and SCI was evaluated with univariable analysis. Adjustments for potential confounders and for the propensity to receive ER or SR were also performed in multivariable analysis. A total of 724 patients (352 ER, 372 SR) underwent repair. The mean age was 67 years, and 65% were male. ER patients were on average 9 years older ( P <0.001), had more comorbid conditions, and more frequently had prior distal repair ( P <0.001) or underwent a type I or IV repair. SR patients more commonly had chronic dissection or required type II or type III repairs ( P <0.001). Mortality at 30 days (5.7% ER versus 8.3% SR, P =0.2) and 12 months (15.6% ER versus 15.9% SR, P =0.9) was similar. A borderline difference in SCI was found between repair techniques: 4.3% of ER and 7.5% of SR patients ( P =0.08) had SCI. In patients with ER, prior distal aortic operation was associated with the development of SCI in univariable analysis (odds ratio 4.1, 95% confidence interval 1.4 to 11.7). Multivariable analysis showed that the type of required repair (type I, II, III, or IV) was the primary factor associated with the development of SCI in ER and SR patients.

Conclusion— No significant difference in the incidence of mortality or SCI was found between ER and SR techniques. The strongest factor associated with SCI remains the extent of the disease. Further studies are indicated to compare ER with patients considered eligible for SR.

Collective Experience with Hybrid Procedures for Suprarenal and Thoracoabdominal Aneurysms

Not every patient is fit for open thoracoabdominal aortic aneurysm (TAAA) repair, nor is every TAAA or juxtarenal abdominal aortic aneurysm suitable for branched or fenestrated endovascular exclusion. The hybrid procedure consists of debranching of the renal and visceral arteries followed by endovascular exclusion of the aneurysm and might be an alternative in these patients.

Between May 2004 and March 2006, 16 patients were treated with a hybrid procedure. The indications were recurrent suprarenal or thoracoabdominal aneurysms after previous abdominal and/or thoracic aortic surgery ( n = 8), type I to III TAAAs ( n = 3), proximal type I endoleak after endovascular repair ( n = 2), penetrating ulcer of the juxtarenal aorta ( n = 1), visceral patch aneurysm after type IV open repair ( n = 1), and primary suprarenal aneurysm ( n = 1). Eight (50%) of 16 patients were judged to be unfit for open TAAA repair.

The hospital mortality rate was 31% (5 of 16). Four of five deceased patients were unfit for thoracophrenic laparotomy. Two patients died from cardiac complications and three from visceral ischemia. No spinal cord ischemia was detected, and temporary renal failure occurred in four patients (25%). The mean follow-up was 13 months (range 6–28 months). During follow-up, no additional grafts occluded and no patients died.

Hybrid procedures are technically feasible but have substantial mortality (31%), especially in patients unfit for open repair (80%). They might be indicated when urgent TAAA surgery is required or when vascular anatomy is unfavorable for fenestrated endografts in patients with extensive previous open aortic surgery.

Endovascular treatment of aortic arch aneurysms

BACKGROUND: Endovascular approach to the aortic arch is an appealing solution for selected patients. OBJECTIVE: To compare the technical and clinical success recorded in the different anatomical settings of endografting for aortic arch disease. METHODS: Between June 1999 and October 2006, among 178 patients treated at our institution for thoracic aorta disease with a stent-graft, the aortic arch was involved in 64 cases. According to the classification proposed by Ishimaru, aortic zone 0 was involved in 14 cases, zone 1 in 12 cases and zone 2 in 38 cases. A hybrid surgical procedure of supra-aortic debranching and revascularization was performed in 37 cases. RESULTS: Zone 0. Proximal neck length: 44±6 mm. Initial clinical success was 78.6%: two deaths (stroke), one type Ia endoleak. At a mean follow-up of 16.4±11 months the midterm clinical success was 85.7%. Zone 1. Proximal neck length: 28±5 mm. Initial clinical success was 66.7%: 0 deaths, four type Ia endoleaks. At a mean follow-up of 16.9±17.2 months the midterm clinical success was 75.0%. Zone 2. Proximal neck length: 30±5 mm. Initial clinical success was 84.2%: two deaths (one cardiac arrest, one multiorgan embolization), three type Ia endoleaks, one case of open conversion. Two cases of delayed transitory paraparesis/paraplegia were observed. At a mean follow-up of 28.0±17.2 months the midterm clinical success was 89.5%. CONCLUSIONS: This study and a literature review demonstrated that hybrid procedure for aortic arch pathology is feasible in selected patients at high risk for conventional surgery. Our experience is still limited by the relatively small sample size. We propose to reserve zone 1 for patients unfit for sternotomy or in cases with aortic neck length > 30 mm following left common carotid artery debranching. We recommend to perform complete aortic rerouting of the aortic arch in cases with lesser comorbidities and shorter aortic neck.

Outcome and quality of life after surgical and endovascular treatment of descending aortic lesions

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) represents an attractive alternative to open aortic repair (OAR). The aim of this study was to assess outcome and quality of life in patients treated either by TEVAR or OAR for diseased descending thoracic aorta.

METHODS

A post hoc analysis of a prospectively collected consecutive series of 136 patients presenting with surgical diseases of the descending aorta between January 2001 and December 2005 was conducted. Fourteen patients were excluded because of involvement of the ascending aorta. Assessed treatment cohorts were TEVAR (n = 52) and OAR (n = 70). Mean follow-up was 34 +/- 18 months. End points were perioperative and late mortality rates and long-term quality of life as assessed by the Short Form Health Survey (SF-36) and Hospital Anxiety and Depression Score questionnaires.

RESULTS

Mean age was significantly higher in TEVAR patients (69 +/- 10 years versus 62 +/- 15 years; p = 0.002). Perioperative mortality rates were 9% (OAR) and 8% (TEVAR), respectively (p = 0.254). Accordingly, cumulative long-term mortality rates were similar in both cohorts. Overall quality-of-life scores were 93 (63-110, OAR) and 83 (60-112, TEVAR), respectively. Normal quality-of-life scores range from 85 to 115. Anxiety and depression scores were not increased after open surgery.

CONCLUSIONS

Thoracic endovascular aortic repair and OAR both provide excellent long-term results in treatment of thoracic aortic disease. Long-term quality of life, however, is reduced after thoracic aortic repair. Interestingly, TEVAR patients did not score higher in overall quality of life despite all advantages of minimized access trauma. Similarly, anxiety and depression scores are not reduced by TEVAR, possibly reflecting a certain caution against the new technology.