Outcomes of endovascular management of acute thoracic aortic emergencies in an academic level 1 trauma center

Clinical outcomes of endovascular treatment for ruptured thoracic aortic disease

BACKGROUND/AIMS

Untreated rupture of the thoracic aorta is associated with a high mortality rate. We aimed to review the clinical results of endovascular treatment for ruptured thoracic aortic disease.

METHODS

We retrospectively reviewed data on 37 patients (mean age, 67.0 ± 15.18 years) treated for ruptured thoracic aortic disease from January 2005 to May 2016. The median follow-up duration was 308 days (interquartile range, 61 to 1,036.5). The primary end-point of the study was the composite of death, secondary intervention, endoleak, and major stroke/paraplegia after endovascular treatment.

RESULTS

The etiologies of ruptured thoracic aortic disease were aortic dissection (n = 11, 29.7%), intramural hematoma (n = 7, 18.9%), thoracic aortic aneurysm (n = 14, 37.8%), and traumatic aortic transection (n = 5, 13.5%). Three patients died within 24 hours of thoracic endovascular aortic repair, and one showed type I endoleak. The technical success rate was 89.2% (33/37). The in-hospital mortality rate was 13.5% (5/37); no deaths occurred during follow-up. The composite outcome rate during follow-up was 37.8% (14/37), comprising death (n = 5, 13.5%), secondary intervention (n = 5, 13.5%), endoleak (n = 5, 13.5%), and major stroke/paraplegia (n = 3, 8.1%). Left subclavian artery revascularization and proximal landing zone were not associated with the composite outcome. Low mean arterial pressure (MAP; ≤ 60 mmHg, [hazard ratio, 13.018; 95% confidence interval, 2.435 to 69.583, p = 0.003]) was the most significant predictor and high transfusion requirement in the first 24 hours was associated with event-free survival (log rank p = 0.018).

CONCLUSION

Endovascular treatment achieves high technical success rates and acceptable clinical outcome. High transfusion volume and low MAP were associated with poor clinical outcomes.

Management of hemothorax after thoracic endovascular aortic repair for ruptured aneurysms

Background Thoracic aortic aneurysm rupture is often a fatal condition. Emergent thoracic endovascular aortic repair (TEVAR) has emerged as a suitable treatment option. Unfortunately, respiratory complications from hemothorax continue to be an important cause of morbidity and mortality even after successful management of the aortic rupture. We hypothesize that early hemothorax decompression after TEVAR for ruptured aneurysms decreases the rate of postoperative respiratory complications. Methods Single-center, retrospective eight-year review of ruptured thoracic aneurysms treated with TEVAR. Results Seventeen patients presented with ruptured degenerative thoracic aortic aneurysms, all of which were successfully treated emergently with TEVAR. The mean age was 74 years among the 12 (70.6%) men and 5 (29.4%) women treated. Inpatient and 30-day mortality rates for the entire cohort were both 17.6% (three patients). The 90-day mortality rate was 47.1% (eight patients). Thirty-day morbidities of the entire cohort included stroke ( n = 1, 5.9%), spinal cord ischemia ( n = 3, 17.6%; only one was temporary), cardiac arrest ( n = 4, 23.5%; 3 were fatal), respiratory failure ( n = 5, 29.4%), and renal failure ( n = 5, 29.4%). A large hemothorax was identified in the majority of patients ( n = 14, 82.4%). While six (42.9% of 14) patients had immediate chest tube decompression on the day of index procedure, three (21.4% of 14) patients had decompression on postoperative day 1, 4, and 7, respectively. Although not statistically significant, there were trends toward higher rates of respiratory failure (50.0% vs. 16.7%, P = 0.198) and 90-day mortality (62.5% vs. 33.3%, P = 0.280) for patients with delayed or no hemothorax decompression when compared to patients with immediate hemothorax decompression. Conclusions The morbidity and mortality of ruptured degenerative thoracic aortic aneurysms remains high despite the introduction of TEVAR. In this single-center experience, there was a trend toward decreased respiratory complications and increased survival with early chest decompression of hemothorax after TEVAR.

Type 2 Diabetes Mellitus and Thoracic Aortic Aneurysm and Dissection: An Observational Population-Based Study in Spain From 2001 to 2012

To describe trends in the rates of discharge due to thoracic aortic aneurysm and dissection (TAAD) among patients with and without type 2 diabetes in Spain (2001-2012).We used national hospital discharge data to select all of the patients who were discharged from the hospital after TAAD. We focused our analysis on patients with TAAD in the primary diagnosis field. Discharges were grouped by diabetes status (diabetic or nondiabetic). Incidence was calculated overall and stratified by diabetes status. We divided the study period into 4 periods of 3 years each. We analyzed diagnostic and surgical procedures, length of stay, and in-hospital mortality.We identified 48,746 patients who were discharged with TAAD. The rates of discharge due to TAAD increased significantly in both diabetic patients (12.65 cases per 100,000 in 2001/2003 to 23.92 cases per 100,000 in 2010/2012) and nondiabetic patients (17.39 to 21.75, respectively). The incidence was higher among nondiabetic patients than diabetic patients in 3 of the 4 time periods.The percentage of patients who underwent thoracic endovascular aortic repair increased in both groups, whereas the percentage of patients who underwent open repair decreased. The frequency of hospitalization increased at a higher rate among diabetic patients (incidence rate ratio 1.14, 95% confidence interval [CI] 1.07-1.20) than among nondiabetic patients (incidence rate ratio 1.08, 95% CI 1.07-1.11). The in-hospital mortality was lower in diabetic patients than in nondiabetic patients (odds ratio 0.83, 95% CI 0.69-0.99).The incidence rates were higher in nondiabetic patients. Hospitalizations seemed to increase at a higher rate among diabetic patients. Diabetic patients had a significantly lower mortality, possibly because of earlier diagnoses, and improved and more readily available treatments.