A Review of the Endovascular Management of Thoracic Aortic Pathology

Hybrid versus in vitro fenestration for preserving the left subclavian artery in patients undergoing thoracic endovascular aortic repair with unfavorable proximal landing zone

Purpose

To compare hybrid and in vitro fenestration procedures for preserving the left subclavian artery in thoracic endovascular aortic repair (TEVAR) with unfavorable proximal landing zone.

Methods

Retrospective comparison of data from 49 consecutive patients who underwent left subclavian artery revascularization during TEVAR by either hybrid or fenestration approaches from January 2015 to March 2018. Procedural duration, and 30-day rates of procedural success, mortality and complications (endoleaks, cerebral infarction, spinal cord ischemia, left arm ischemic symptoms, and delirium) were compared.

Results

For hybrid procedure ( n = 32) vs. fenestration ( n = 17) groups, which were age and gender matched: procedural success rate was 100%, with significantly longer procedural duration (248.4 ± 40.9 vs. 60.6 ± 16.8 min; t = –22.653, P = 0.000) and similar 30-day complication rate (18.8% vs. 11.8%; χ2 = 0.397, P = 0.529). At 12.7 ± 9.3 months’ follow-up, there were no cases of death, spinal cord ischemia, or other complications in either group.

Conclusions

In this retrospective, single-center comparison, both hybrid and in vitro fenestration approaches for reconstructing the left subclavian artery in TEVAR with unfavorable proximal landing zone appeared safe and effective, with shorter procedural duration for fenestration. Larger studies with longer term follow-up are warranted.

A review of endovascular treatment of thoracic aorta disease

INTRODUCTION

The development of thoracic endovascular aortic repair has altered the approach and reduced the risk of treating the majority of descending thoracic aortic conditions. Primarily developed for the exclusion of thoracic aortic aneurysms, it is now used in place of open repair surgery for most descending thoracic aortic diseases, and has also been used to treat aortic arch diseases in selected cases.

METHODS

A literature search was conducted of Medline and Embase databases from January 2007 to February 2017, using the key words 'aortic disease', 'thoracic aorta' and 'endovascular repair'; 205 articles were identified, of which 25 studies were selected for review based on their relevance.

FINDINGS

The key findings of the indications, techniques, outcomes, complications and comparisons with open surgical repair were extracted from the published studies and are summarised in this review. Thoracic endovascular aortic repair is the preferred choice of intervention for patients with descending thoracic aortic disease. With time, it has improved to be safer and has the potential to expand aortic treatment choices in future.

Emergent aortic surgery in octogenarians: is the advanced age a contraindication?

Surgery of both the ascending and descending aortic segments in the context of an acute aortic syndrome is one of the greatest challenges for the cardiac surgeon. In the case of surgery of the descending aorta, surgical risk increases due to the technical complexity, the required aggressive approach and because surgical indication is usually established as a result of complications and therefore involves, almost always, critically ill patients. The aging of the population is causing such surgery to be considered in an increasing number of octogenarians. The present review analyzes the available scientific evidence on the surgical indications and outcomes of these complex procedures in this population, particularly in the emergent scenario. Ascending and descending thoracic aortic diseases are reviewed separately, and the role of both the current risk scores and frailty assessments are comprehensively discussed.

Impact of age and urgency on survival after thoracic endovascular aortic repair

OBJECTIVE

Elderly patients are often turned down from receiving treatment for descending thoracic aortic diseases (DTADs) because of the uncertain benefits, especially in acute settings. This study investigated the impact of old age and timing of thoracic endovascular aortic repair (TEVAR) on outcomes of DTAD in patients older than 75 years of age.

METHODS

Patients from a prospective TEVAR database were dichotomized by age (75 and 80 years of age). Older and young patients were compared in three timing scenarios: (1) elective procedures, (2) any emergency (within 15 days from onset), and (3) acute ruptures (any emergency subgroup). Primary outcome was perioperative mortality assessed at 30 and 90 days.

RESULTS

Between 2003 and 2015, 141 consecutive TEVARs (71.6% men) were performed. Fifty-seven patients (40.4%) were older than 75 years of age; 28 were octogenarians. Eighty-three TEVARs were performed electively and 58 emergently. Among overall emergencies, 42 TEVARs were for acute ruptures. In the elective scenario, the 30-day mortality rate was 5.0% vs 0 (odds ratio [OR], 1.1; 95% confidence interval [CI], 0.98-1.1; P = .23), and 90-day mortality was 7.5% vs 0, for patients older than 75 years of age vs those who were younger than 75, respectively (P = .11). No octogenarian died. In the emergency scenario, 30-day mortality was 41.2% vs 9.8%, for patients older than 75 years of age vs those who were younger than 75, respectively (OR, 6.5; 95% CI, 1.6-26.6; P = .01) with unchanged rates at 90 days. The mortality rate was 50% for octogenarians. In the acute rupture scenario, 30-day mortality was 40% vs 11.1% (OR, 5.3; 95% CI, 1.10-25.99; P = .05) for patients older than 75 years of age vs those younger than 75 years of age and 46% vs 10% (OR, 7.5; 95% CI, 1.47-37.46; P = .016) for octogenarians vs younger patients. Rates remained unchanged at 90 days. Patients older than age 75 survived for a mean of 53.98 ± 7.7 months after TEVAR.

CONCLUSIONS

In the elderly patient population with DTAD, mortality risks from TEVAR are strongly related to timing and age. When compared to younger patients, those older than 75 years of age have three to five times the risk of mortality after urgent or emergent TEVAR. However, older patients should still be considered for emergent life-saving treatment, given that the majority survives.