Pathology-specific secondary aortic interventions after thoracic endovascular aortic repair

Endovascular Repair in Blunt Thoracic Aortic Injury: A 10-Year Single Center Experience

BACKGROUND

Life-threatening blunt thoracic aortic injury (BTAI) typically occurs alongside multiple other traumatic injuries. Symptoms of BTAI can range from being asymptomatic in the case of intimal tears to becoming catastrophic in the case of uncontained aortic ruptures. The aim of this research was to examine the clinical outcomes for those who underwent thoracic endovascular aortic repair (TEVAR) in hospital settings.  Methods: A cross-sectional retrospective study was conducted using patient data that were extracted from Al-Noor Specialist Hospital, Makkah, Saudi Arabia, for the duration between January 2011 and December 2021. This study included data from all patients aged 18 and up who had been diagnosed with BTAI and had undergone TEVAR. The BTAI diagnoses were confirmed using CT scans. Logistic regression was utilized to identify predictors of patients' health status improvement and length of stay.

RESULTS

A total of 80 patients were involved. Around 50.0% (n=40) of the patients had grade 3 thoracic aortic injuries. The median duration of stay was 14.00 days (Interquartile range 21.00). Only one patient developed post-procedure complications (1.3%). Almost one-third (31.3%; n=25) of the patients required subclavian coverage. One patient developed intraoperative endoleak (1.3%). One patient developed an access site complication (1.3%). The mortality rate within 30 days of the operation was 1.3%. The vast majority of the patients (92.5%; n=74) showed improvement upon discharge from the hospital. The baseline patient characteristics and length of hospitalization had no effect on the improvement of patient status upon discharge or their length of stay (p>0.05).

CONCLUSION

Patients with BTAI have shown an excellent success rate with TEVAR and a low complication rate. Predictors of procedure success and length of stay need to be identified; however, this can't be done without larger-scale investigations. This can aid in the development of preventative measures that improve clinical outcomes for the patients.

Early Versus Delayed Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury: A Propensity Score-Matched Analysis

OBJECTIVE

We examined early (≤24 h) versus delayed (>24 h) thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI), taking the aortic injury severity into consideration.

BACKGROUND

Current trauma surgery guidelines recommend delayed TEVAR following BTAI. However, this recommendation was based on small studies, and specifics regarding recommendation strategies based on aortic injury grades are lacking.

METHODS

Patients undergoing TEVAR for BTAI in the American College of Surgeons Trauma Quality Improvement Program between 2016 and 2019 were included and then stratified into 2 groups (early: ≤24 h vs. delayed: >24 h). In-hospital outcomes were compared after creating 1:1 propensity score-matched cohorts, matching for demographics, comorbidities, concomitant injuries, additional procedures, and aortic injury severity based on the acute aortic syndrome (AAS) classification.

RESULTS

Overall, 1339 patients were included, of whom 1054(79%) underwent early TEVAR. Compared with the delayed group, the early group had significantly less severe head injuries (early vs delayed; 25% vs 32%; P =0.014), fewer early interventions for AAS grade 1 occurred, and AAS grade 3 aortic injuries often were intervened upon within 24 hours (grade 1: 28% vs 47%; grade 3: 49% vs 23%; P <0.001). After matching, the final sample included 548 matched patients. Compared with the delayed group, the early group had a significantly higher in-hospital mortality (8.8% vs 4.4%, relative risk: 2.2, 95% CI: 1.1-4.4; P =0.028), alongside a shorter length of hospital stay (5.0 vs 10 days; P =0.028), a shorter intensive care unit length of stay (4.0 vs 11 days; P <0.001) and fewer days on the ventilator (4.0 vs 6.5 days; P =0.036). Furthermore, regardless of the higher risk of acute kidney injury in the delayed group (3.3% vs 7.7%, relative risk: 0.43, 95% CI: 0.20-0.92; P =0.029), no other differences in in-hospital complications were observed between the early and delayed group.

CONCLUSION

In this propensity score-matched analysis, delayed TEVAR was associated with lower mortality risk, even after adjusting for aortic injury grade.

Outcomes following thoracic endovascular aortic repair for blunt thoracic aortic injury stratified by Society for Vascular Surgery grade

OBJECTIVES

Although the Society for Vascular Surgery (SVS) aortic injury grading system is used to depict the severity of injury in patients with blunt thoracic aortic injury, prior literature on its association with outcomes after thoracic endovascular aortic repair (TEVAR) is limited.

METHODS

We identified patients undergoing TEVAR for BTAI within the VQI between 2013 and 2022. We stratified patients based on their SVS aortic injury grade (grade 1, intimal tear; grade 2, intramural hematoma; grade 3, pseudoaneurysm; and grade 4, transection or extravasation). We assessed perioperative outcomes and 5-year mortality using multivariable logistic and Cox regression analyses. Secondarily, we assessed the proportional trends in patients undergoing TEVAR based on SVS aortic injury grade over time.

RESULTS

Overall, 1311 patients were included (grade1, 8%; grade 2, 19%; grade 3, 57%; grade 4, 17%). Baseline characteristics were similar, except for a higher prevalence of renal dysfunction, severe chest injury (Abbreviated Injury Score >3), and lower Glasgow Coma Scale with increasing aortic injury grade (Ptrend < .05). Rates of perioperative mortality by aortic injury grade were as follows: grade 1, 6.6%; grade 2, 4.9%; grade 3, 7.2%; and grade 4, 14% (Ptrend = .003) and 5-year mortality rates were 11% for grade 1, 10% for grade 2, 11% for grade 3, and 19% for grade 4 (P = .004). Patients with grade 1 injury had a high rate of spinal cord ischemia (2.8% vs grade 2, 0.40% vs grade 3, 0.40% vs grade 4, 2.7%; P = .008). After risk adjustment, there was no association between aortic injury grade and perioperative mortality (grade 4 vs grade 1, odds ratio, 1.3; 95% confidence interval, 0.50-3.5; P = .65), or 5-year mortality (grade 4 vs grade 1, hazard ratio, 1.1; 95% confidence interval, 0.52-2.30; P = .82). Although there was a trend for decrease in the proportion of patients undergoing TEVAR with a grade 2 BTAI (22% to 14%; Ptrend = .084), the proportion for grade 1 injury remained unchanged over time (6.0% to 5.1%; Ptrend = .69).

CONCLUSIONS

After TEVAR for BTAI, there was higher perioperative and 5-year mortality in patients with grade 4 BTAI. However, after risk adjustment, there was no association between SVS aortic injury grade and perioperative and 5-year mortality in patients undergoing TEVAR for BTAI. More than 5% of patients with BTAI who underwent TEVAR had a grade 1 injury, with a concerning rate of spinal cord ischemia potentially attributable to TEVAR, and this proportion did not decrease over time. Further efforts should focus on enabling careful selection of patients with BTAI who will experience more benefit than harm from operative repair and preventing the inadvertent use of TEVAR in low-grade injuries.

Males and females have similar mortality after thoracic endovascular aortic repair for blunt thoracic aortic injury

OBJECTIVE

Prior literature has demonstrated worse outcomes for female patients after abdominal aortic aneurysm repair. Also, prior studies in the context of thoracic endovascular aneurysm repair (TEVAR) for thoracic aortic aneurysms have reported conflicting results regarding sex-related outcomes. Because the influence of sex on the outcomes after TEVAR for blunt thoracic aortic injuries (BTAIs) remains understudied, we evaluated the association between sex and outcomes after TEVAR for BTAI.

METHODS

We identified patients who had undergone TEVAR for BTAIs in the Vascular Quality Initiative registry from 2013 to 2022 and included those who had undergone TEVAR within zones 2 to 5 of the thoracic aorta. Patients with missing information regarding the aortic injury grade (Society for Vascular Surgery aortic injury grading system) were excluded. We performed multivariable logistic regression and Cox regression to determine the influence of sex on the perioperative outcomes and long-term mortality, respectively.

RESULTS

We identified 1311 patients, of whom 27% were female. The female patients were significantly older (female, 47 years [interquartile range (IQR), 30-63 years]; male, 38 years [IQR, 28-55 years]; P < .001) with higher rates of comorbidities. Although the female patients had had higher Glasgow coma scale scores (median, 15 [IQR, 11-15]; vs 14 [IQR, 8-15]; P = .028), no differences were found in the aortic injury grade or other coexisting traumatic injuries between the sexes. Apart from the longer procedure duration for the female patients (median, 79 minutes [IQR, 52-119 minutes]; vs 69 minutes [IQR, 48-106 minutes]; P = .008), the procedural characteristics were comparable. After adjustment, no significant association was found between female sex and perioperative mortality (7.1% vs 8.1%; odds ratio, 0.76; 95% confidence interval [CI], 0.43-1.3; P = .34). The male and female patients had had comparable rates of postoperative complications (26% vs 29%; odds ratio, 0.89; 95% CI: 0.52-1.5]; P = .26) including access-related complications (0.5% vs 0.8%; P=.83). However, females had a significantly higher risk for reintervention during the index admission (odds ratio, 2.5; 95% CI, 1.1-5.5; P = .024). No significant difference was found between the male and female patients with respect to 5-year mortality (hazard ratio, 0.87; 95% CI, 0.57-1.35; P = .50).

CONCLUSIONS

Unlike the sex-based outcome disparities observed after thoracic aortic aneurysm repair, we found no significant association between sex and perioperative outcomes or long-term mortality after TEVAR for BTAIs. This contrast in the sex-related outcomes after other vascular pathologies might be explained by differences in the pathology, demographics, and anatomic factors in these patients.

LONG-TERM OUTCOMES AND RISK FACTORS ANALYSIS FOR PATIENTS UNDERGOING THORACIC ENDOVASCULAR AORTA REPAIR (TEVAR), ACCORDING TO THE AORTIC PATHOLOGIES

OBJECTIVE

Thoracic endovascular aortic repair (TEVAR) has become a standard treatment for acute and chronic thoracic aorta diseases. We analysed long-term outcomes and risk factors of TEVAR procedures according to the aortic pathology.

METHODS

Demographics, indications, technical details, and outcomes of patients undergoing TEVAR procedures in our institutions were prospectively collected and retrospectively analyzed. Overall survival was determined using Kaplan-Meier methods while Log-rank tests were used to compare the survival between groups. Cox regression analysis was used to identify risk factors.

RESULTS

Between June 2002 and April 2020, 116 patients underwent TEVAR for different thoracic aorta diseases. Among them, 47 patients (41%) underwent TEVAR for aneurysmatic aortic disease, 26 (22%) for type-B aortic dissection, 23 (20%) for penetrating aortic ulcer, 11 (9%) after previous type-A dissection treatment and 9 (8%) for traumatic aortic injury. Patients with post-traumatic aortic injury were younger (p<0.01), with less hypertension (p<0.01), diabetes (p<0.01) and prior cardiac surgery (p<0.01). Survival was different based on indication for TEVAR (log rank 0.024). Patients after previous type-A dissection treatment had the worst survival rate (50% at 5 years) while survival for aneurysmatic aortic disease was 55% at 5 years. No late death occurred in the traumatic group. Cox-regression model identified independent predictors for mortality: age (HR 1.05, 95% CI 1.01-1.09, p= 0.006), male gender (HR 3.2, 95% CI 1.1-9.2, p=0.028), moderate COPD (HR 2.1, 95% CI 1.02-4.55, p=0.043), previous cardiac surgery (HR 2.1, 95% CI 1.008-4.5, p=0.048), and treatment indication for aneurysm (HR 2.6, 95% CI 1.2-5.2, p=0.008).

CONCLUSIONS

TEVAR is a safe and effective procedure with excellent long-term results in case of traumatic aortic injury. The overall long-term survival is affected by aortic pathology, associated comorbidities, gender and previous cardiac surgery.

Evaluation and Management of Complications of Endovascular Aneurysm Repair of the Thoracic Aorta

Thoracic endovascular aortic repair (TEVAR) has become the standard of care for descending thoracic aortic pathology as the procedure has a historically low rate of reintervention and a high rate of success. However, TEVAR can be associated with complications such as endoleak, upper extremity limb ischemia, cerebrovascular ischemia, spinal cord ischemia, and post-implantation syndrome. An 80-year-old man with a history of complex thoracic aortic aneurysms underwent repair of a large thoracic aneurysm with a frozen elephant trunk procedure in 2019 at an outside institution. The proximal aortic graft extended to the arch and the innominate and left carotid artery were implanted into the distal portion of the graft. The endograft, extending from the proximal graft to the descending thoracic aorta, was fenestrated to maintain left subclavian artery flow. In an attempt to gain a seal at the fenestration, a Viabahn graft (Gore, Flagstaff, AZ, USA) was inserted. A type III endoleak was identified postoperatively at the fenestration, and a second Viabahn graft was required to gain a seal during the initial hospitalization. In 2020, an endoleak persisted at the fenestration on follow-up imaging, but the aneurysmal sac was stable. No intervention was recommended. The patient later presented to our institution with three days of chest pain. A type III endoleak at the level of the subclavian fenestration persisted with significant enlargement of the aneurysm sac. The patient underwent an urgent repair of the endoleak. This consisted of covering the fenestration with an endograft and left carotid to subclavian bypass. Subsequently, the patient developed a transient ischemic attack (TIA) due to kinking and extrinsic compression by the large aneurysm sac of the proximal left common carotid artery, requiring a right carotid to left carotid-axillary graft bypass. This report with a literature review discusses TEVAR complications and outlines methods to approach them. TEVAR complications and their management should be firmly understood to improve overall treatment outcomes.

Aortic-related Readmission after Thoracic Endovascular Aortic Repair for Type B Aortic Dissection Patients: A Single-center Retrospective Study

OBJECTIVES

This study aimed to investigate the characteristics of and risk factors for aortic-related readmission after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD).

METHODS

Data from TBAD patients who underwent TEVAR from 2009-2018 at a Chinese tertiary center were retrospectively collected and analyzed. Enrolled patients were categorized into two groups according to whether aortic-related readmission occurred during follow-up, which was defined as hospitalization at least once after the initial procedure due to events that were related to or caused by aortic dissection or the initial procedure.

RESULTS

A total of 1 288 TBAD patients were enrolled, and 99 patients experienced aortic-related readmissions (7.7%), among whom chronic patients had the highest readmission rate (9.8%). The yearly proportion of readmission during the first year after initial procedure revealed a decreasing trend with a -9.7% annual percentage change. Seventy-one patients underwent reintervention (71.7%). Distal aneurysmal degeneration (43.7%) and distal stent graft-induced new entries (32.4%) were two major causes for reintervention. Fourteen patients in the reintervention subgroup underwent a second reintervention (19.7%). In-hospital mortality was 1.0% during the readmission and 14.3% during the second readmission. The overall survival was comparable between two groups (p=.93).

CONCLUSIONS

This study highlighted the importance of surveillance after initial procedure for TBAD patients with potential risk factors for aortic-related readmission, and the predisposition of patients with reintervention to multiple readmissions deserves attention.

Unique characteristics of the type B aortic dissection patients with malperfusion in the Vascular Quality Initiative

OBJECTIVE

Type B aortic dissection (TBAD) complicated by malperfusion carries high morbidity and mortality. The present study was undertaken to compare the characteristics of malperfusion and uncomplicated cohorts and to evaluate the long-term differences in survival using a granular, national registry.

METHODS

Patients with TBAD entered into the thoracic endovascular aortic repair/complex endovascular aortic repair module of the Vascular Quality Initiative from 2010 to 2019 were included. The demographic, radiographic, operative, postoperative, in-hospital, and long-term reintervention data were compared between the malperfusion and uncomplicated TBAD groups using t tests and χ² analysis, as appropriate. Overall survival was compared using Cox regression to generate survival curves.

RESULTS

Of the 2820 included patients, 2267 had uncomplicated TBAD and 553 had malperfusion. The patients with malperfusion were younger (age, 55.8 vs 61.2 years; P < .001), were more often male (79.7% vs 68.1%; P < .001), had a higher preoperative creatinine (1.8 vs 1.1 mg/dL; P < .001), had more often presented with an American Society of Anesthesiologists class of 4 or 5 (81.9% vs 58.4%; P < .001), and had more often presented with urgent status (77.4% vs 32.8%; P < .001). In contrast, the uncomplicated TBAD group had had more medical comorbidities, including coronary artery disease and chronic obstructive pulmonary disease, and a larger aortic diameter (4.0 cm vs 4.9 cm; P < .001). The malperfusion group more frequently had proximal zones of disease in zones 0 to 2 (38.6% vs 31.5%; P = .002) and distal zones of disease in zones 9 and above (78.7% vs 46.2%; P < .001), with a greater number of aortic zones traversed (7.7 vs 5.1; P < .001) and a greater frequency of dissection extension into branch vessels (61.8% vs 23.1%; P < .001). Patients with malperfusion also exhibited greater case complexity, with a greater need for branch vessel stenting and longer procedure times. The overall incidence of postoperative complications was greater in the malperfusion group (39.4% vs 17.1%; P < .001) and included a greater rate of spinal cord ischemia (6.3% vs 2.2%; P < .001), acute kidney injury (10.4% vs 0.9%; P < .001), and in-hospital mortality (11.6% vs 5.6%; P < .001). In-hospital reintervention was also greater for the malperfusion patients (14.5% vs 7.4%; P < .001), although the incidence of long-term reinterventions was similar between the two groups (8.7% vs 9.7%; P = .548). A proximal zone of disease in zone 0 to 2 was associated with decreased survival. In contrast, a distal zone of disease in 9 and above, in-hospital reintervention, and long-term follow-up were associated with increased survival. Despite these differences, long-term survival did not differ between the malperfusion and uncomplicated groups (P = .320.) CONCLUSIONS: Patients presenting with TBAD and malperfusion represent a unique cohort. Despite the greater need for branch vessel stenting and in-hospital reintervention, they had similar long-term reintervention rates and survival compared with those with uncomplicated TBAD. These data lend insight with regard to the observed differences between uncomplicated and malperfusion TBAD.

Drag Forces after Thoracic Endovascular Aortic Repair. General Review of the Literature

BACKGROUND

Despite the great evolution of endograft devices for thoracic endovascular aortic repair (TEVAR), threatening related complication such as graft migration and endoleaks still occur during follow up. The Drag Forces (DF), that is the displacement forces that play a role in graft migration and endoleaks caused by the blood flow against the thoracic graft, can be studied by means of Computational Fluid Dynamics (CFD).

METHOD

A general review of papers found in current literature was performed. CFD studies available on the topic of thoracic aortic diseases and DF were analyzed. All anatomic, hemodynamics or graft related factors which could have an impact on DF were reported.

RESULTS

Different factors deeply influence DF magnitude in the different site of the Ishimaru's zones classification: angulation, tortuosity and length of the landing zone, graft diameter, length and deployment position, blood pressure, pulse waveform, blood viscosity and patient heart rate have been related to the magnitude of DF. Moreover, also the three-dimensional orientation of DF is emerging as a fundamental issue from CFD studies. DF can be divided in sideways and upward components. The former, even of higher magnitude in zone 0, maintain always an orthogonal orientation and does not change in any type of aortic arch; the latter result strictly related to the anatomic complexity of the aortic arch with values up to four times higher in zone 3.

CONCLUSION

Different DF magnitude and orientation could explain how TEVAR have higher rate of migration and endoleaks when we face with more complex aortic anatomies. All these aspects should be foreseen during the planning of TEVAR procedure. In this field, collaboration between physicians and engineers is crucial, as both parts have a primary role in understanding and describing hidden aspects involved in TEVAR procedures.

Outcomes of thoracic endovascular aortic repair in thoracic aortic aneurysm and penetrating aortic ulcer using the Conformable Gore TAG within and outside the instructions for use

OBJECTIVE

To describe the outcome of thoracic endovascular aortic repair (TEVAR) in thoracic aortic aneurysm and penetrating aortic ulcer with respect to instructions for use status.

METHODS

Between October 2009 and September 2017, a total of 532 patients underwent TEVAR; of which 195 have been treated using the Conformable GORE® TAG® thoracic endoprosthesis (CTAG). Fifty-six patients of this cohort underwent TEVAR for thoracic aortic aneurysm/penetrating aortic ulcer using the CTAG. Depending on the preoperative computed tomography angiography findings, patients were classified as inside or outside the device's instructions for use. All inside instruction for use patients underwent postoperative reclassification regarding the instructions for use status. Study endpoints included TEVAR-related reintervention, exclusion of the pathology (endoleak type I/III), TEVAR-related mortality, and graft-related serious adverse events. The median duration of follow-up was 29.7 months (range: 0-109.4 months).

RESULTS

Of the 56 patients, 17 were primarily classified as outside instruction for use, and in additional 13 patients, TEVAR was performed outside instruction for use, leading to 30 outside instruction for use patients (53.6%). Twenty-six patients (46.4%) were treated inside instruction for use. Reintervention-free survival was lower in outside instruction for use patients (P = 0.016) with a hazard ratio of 9.74 (confidence interval 1.2-80.2; P = 0.034) for TEVAR-related reintervention. With respect to endoleak type I/III, relevant difference was detected between inside/outside instruction for use status (P = 0.012). The serious adverse event rate was 30.4%, mainly in outside instruction for use patients (P = 0.004). Logistic regression analysis indicated an association between graft-related serious adverse event/instructions for use status (odds ratio 6.11; confidence interval 1.6-30.06; P = 0.012). In-hospital death was seen more frequently in outside instruction for use patients (P = 0.12) as was procedure-related death (log-rank test: P = 0.21).

CONCLUSION

TEVAR for thoracic aortic aneurysm/penetrating aortic ulcer is frequently performed outside instruction for use despite preoperative inside instruction for use eligibility, leading to important consequences for technical/clinical outcome. Instructions for use adherence in TEVAR should be of interest for further large-scale studies.

Current Status of Endoluminal Treatment of Descending Thoracic Aortic Aneurysms

Thoracic endovascular aortic repair (TEVAR) was proved to be effective in thoracic descending aortic aneurysm (TDAA) repair in 1994 and approved by the FDA in 2005. Since then, TEVAR has become the first-line, recommended treatment for intact or ruptured DTAA or as a bridge to definitive open surgical repair in connective tissue disease. TEVAR has decreased perioperative morbidity and mortality compared to open surgery due to the lack of thoracotomy, aortic cross-clamping and left heart bypass. Improvement in materials, manufacturing and device delivery systems have allowed for the expansion of indications. Thoughtful and accurate pre-procedure planning is the hallmark of successful TEVAR. Familiarization and adherence to the instructions for use for an aortic device will give the best possible chance of success.

Total Aortic Arch Replacement after Thoracic Endovascular Aortic Repair Using Left Subclavian Arterial Perfusion

We present the case of an 86-year-old male with an aortic arch saccular aneurysm who underwent zone 1 thoracic endovascular aortic repair (TEVAR) with debranching from the right subclavian artery to the left carotid and left subclavian arteries. The patient developed a type Ia endoleak 1 month later. Postoperative contrast computed tomography (CT) showed a hematoma around the aneurysm, concerning for impending rupture. He thus underwent emergency endograft removal and replacement with a one-branched graft using selective cerebral perfusion via the left subclavian artery perfusion. The left subclavian artery was used for systemic and cerebral perfusion without need for cannulation of the cervical arteries. The patient was successfully discharged 6 months after surgery.

Overall survival and factors predicting long-term outcome after thoracic aortic endovascular repair

PURPOSES

To assess overall survival and to determine factors predicting outcome after thoracic endovascular aortic repair.

MATERIALS AND METHODS

A Retrospective analysis was performed on a cohort of 212 consecutive patients (165 men and 47 women; mean age 64 years) who underwent thoracic endovascular aortic repair in a tertiary referral center for aortic disease. Main indications were true thoracic aortic aneurysm (n = 58; 27.6%), traumatic aortic rupture (n = 33; 15.7%), anastomotic pseudoaneurysms (n = 23; 10.9%), chronic type B aortic dissection (n = 22; 10.5%), and symptomatic, acute type B dissection (n = 21; 10.0%). In 79 patients (37.3%), a hybrid procedure, including supra-aortic rerouting, was performed. Kaplan-Meier estimates were used for overall survival and Cox regression models were used for univariable analysis of the association between risk factors and survival.

RESULTS

Proximal landing zones were predominantly zone 3 (n = 66; 31.3%), zone 2 (n = 63; 29.9%), and zone 1 (n = 38; 18%). In-hospital mortality was n = 18 (8.5%). Overall survival was 79.6%, 65.9%, and 51.1% at 2, 5, and 10 years, respectively; better overall survival was shown for traumatic aortic rupture, anastomotic pseudoaneurysms, and chronic posttraumatic pseudoaneurysms (p < 0.05). Clinical risk factors influencing overall survival include prior coronary bypass surgery, atrial flutter, arterial hypertension, renal failure, chronic obstructive pulmonary disease, and associated abdominal aortic aneurysm (p < 0.05).

CONCLUSIONS

Thoracic endovascular aortic repair is an effective treatment option for various thoracic aortic diseases with highest survival rates for traumatic aortic rupture and anastomotic pseudoaneurysms. Several clinical parameters are identified as risk factors for overall survival.

Reinterventions in the modern era of thoracic endovascular aortic repair

OBJECTIVE

Using a national data set, we sought to describe the population of patients and the nature and timing of reinterventions after thoracic endovascular aortic repair (TEVAR) by aortic disease as well as their impact on survival.

METHODS

We evaluated the national data set for TEVAR in the Vascular Quality Initiative from 2010 to 2017. Student t-test and χ² analysis were used to compare continuous and categorical variables in the reintervention and no reintervention groups, respectively. Freedom from reintervention and survival analysis was performed using Kaplan-Meier methods.

RESULTS

A total of 7006 patients were evaluated: 51.2% thoracic aortic aneurysm, 33.5% type B dissection (TBD), 7.0% penetrating aortic ulcer, 6.7% trauma, and 1.6% intramural hematoma. Overall, 553 patients (7.9%) underwent at least one reintervention, with an in-hospital reintervention rate of 3.5%. Reinterventions were most commonly performed for TBD (11.5%), with reinterventions for other diseases occurring at lower rates: thoracic aortic aneurysm, 6.7%; intramural hematoma, 5.4%; penetrating aortic ulcer, 4.8%; and trauma, 1.8%. The most common cause of reintervention across all aortic diseases was type I endoleak. The most common long-term reinterventions were placement of endovascular stent graft (65%), other surgical treatments (15.9%), other endovascular treatment (13%), endovascular branch treatment (12.4%), surgical treatment with no device removal (11.0%), and surgical branch treatment (10.4%). Freedom from reintervention was decreased for TBD compared with other diseases (P < .001). There was no difference in survival comparing patients undergoing reinterventions and those without (P = .87). However, patients undergoing in-hospital reintervention trended toward increased mortality (P = .075).

CONCLUSIONS

Whereas reinterventions were not rare after TEVAR, there was no difference in mortality between patients undergoing reintervention and those without. Patients undergoing TEVAR for TBD demonstrated the highest reintervention rate. This study highlights the importance of long-term follow-up to address disease-specific patterns of reintervention.

Endovascular management of penetrating and non-penetrating aortic injury

Aortic trauma is a devastating injury often associated with significant polytrauma. Penetrating injury of the aorta is highly lethal and therefore rarely encountered in the hospital setting. The management of blunt trauma of the aorta has changed significantly over the past decade, principally due to improved imaging technology and the development of endovascular therapy. The most common site of injury is the proximal descending thoracic aorta. The degree of aortic wall injury guides the indication for therapy, while a combination of the degree of injury and the extent of co-morbid injuries drives the timing of repair. Lower grade injuries frequently do not require any surgical intervention. Thoracic aortic endograft repair can be performed in a safe, expeditious fashion. Short-term and mid-term outcomes appear excellent, with patient survival based mainly on concomitant traumatic injuries. Long-term outcomes are less well known. Future endeavors will be guided toward gaining a better understanding of the indications for repair and the long-term outcomes for endograft devices designed for this purpose.

Complications of endovascular aneurysm repair of the thoracic and abdominal aorta: evaluation and management

In recent decades, endovascular aneurysm repair or endovascular aortic repair (EVAR) has become an acceptable alternative to open surgery for the treatment of thoracic and abdominal aortic aneurysms and other aortic pathologies such as the acute aortic syndromes (e.g., penetrating aortic ulcer, intramural hematoma, dissection). Available data suggest that endovascular repair is associated with lower perioperative 30-day all-cause mortality as well as a significant reduction in perioperative morbidity when compared to open surgery. Additionally, EVAR leads to decreased blood loss, eliminates the need for cross-clamping the aorta and has shorter recovery periods than traditional surgery. It is currently the preferred mode of treatment of thoracic and abdominal aortic aneurysms in a subset of patients who meet certain anatomic criteria conducive to endovascular repair. The main disadvantage of EVAR procedures is the high rate of post-procedural complications that often require secondary re-intervention. As a result, most authorities recommend lifelong imaging surveillance following repair. Available surveillance modalities include conventional radiography, computed tomography, magnetic resonance angiography, ultrasonography, nuclear imaging and conventional angiography, with computed tomography currently considered to be the gold standard for surveillance by most experts. Following endovascular abdominal aortic aneurysm (AAA) repair, the rate of complications is estimated to range between 16% and 30%. The complication rate is higher following thoracic EVAR (TEVAR) and is estimated to be as high as 38%. Common complications include both those related to the endograft device and systemic complications. Device-related complications include endoleaks, endograft migration or collapse, kinking and/or stenosis of an endograft limb and graft infection. Post-procedural systemic complications include end-organ ischemia, cerebrovascular and cardiovascular events and post-implantation syndrome. Secondary re-interventions are required in approximately 19% to 24% of cases following endovascular abdominal and thoracic aortic aneurysm repair respectively. Typically, most secondary reinterventions involve the use of percutaneous techniques such as placement of cuff extension devices, additional endograft components or stents, enhancement of endograft fixation, treatment of certain endoleaks using various embolization techniques and embolic agents and thrombolysis of occluded endograft components. Less commonly, surgical conversion and/or open surgical modification are required. In this article, we provide an overview of the most common complications that may occur following endovascular repair of thoracic and AAAs. We also summarize the current surveillance recommendations for detecting and evaluating these complications and discuss various current secondary re-intervention approaches that may typically be employed for treatment.

Secondary Open Aortic Procedure Following Thoracic Endovascular Aortic Repair: Meta-Analytic State of the Art

BACKGROUND

Thoracic endovascular aortic repair is characterized by a substantial need for reintervention. Secondary open aortic procedure becomes necessary when further endoluminal options are exhausted. This synopsis and quantitative analysis of available evidence aims to overcome the limitations of institutional cohort reports on secondary open aortic procedure.

METHODS AND RESULTS

Electronic databases were searched from 1994 to the present date with a prospectively registered protocol. Pooled quantification of pre/intraoperative variables, and proportional meta-analysis with random effect model of early and midterm outcomes were performed. Subgroup analysis was conducted for patients who had early mortality. Fifteen studies were elected for final analysis, encompassing 330 patients. The following values are expressed as "pooled mean, 95% confidence interval." Type B dissection was the most common pathology at index thoracic endovascular aortic repair (51.2%, 44.4-57.9). The most frequent indication for secondary open aortic procedure was endoleak (39.7%, 34.6-45.1). More than half of patients had surgery on the descending aorta (51.2%, 45.8-56.6), and one fourth on the arch (25.2%, 20.8-30.1). Operative mortality was 10.6% (7.4-14.9). Neurological morbidity was substantial between stroke (5.1%, 2.8-9.1) and paraplegia (8.3%, 5.2-13.1). At 2-year follow-up, mortality (20.4%, 11.5-33.5) and aortic adverse event (aortic death 7.7%, 4.3-13.3, tertiary aortic open procedure 7.4%, 4.0-13.2) were not negligible.

CONCLUSIONS

In the secondary open aortic procedure population, type B dissection was both the most common pathology and the one associated with the lowest early mortality, whereas aortic infection and extra-anatomical bypass were associated with the most ominous prognosis.

Initial and midterm results of the Bolton Relay Thoracic Aortic Endovascular Pivotal Trial

OBJECTIVE

To report the initial and midterm results of the Bolton Relay Thoracic Stent Graft for the endovascular treatment of thoracic aortic lesions [thoracic endovascular aortic repair (TEVAR)].

METHODS

The Bolton Relay Thoracic Aortic Endovascular Pivotal Trial was a prospective, nonrandomized, multicenter, U.S. Investigational Device Exemption study conducted at 27 U.S. investigational sites. One hundred twenty TEVAR subjects were treated with the Relay device between January 2007 and May 2010, with 13 patients enrolled during the continued access phase through September 2012. TEVAR outcomes were compared with a prospectively and retrospectively enrolled surgical cohort consisting of 60 patients enrolled under similar inclusion/exclusion criteria. Follow-up examinations were prescribed at 1 month, 6 months, and yearly thereafter for 5 years. Major adverse events (MAEs) included stroke, paralysis/paraplegia, myocardial infarction, procedural bleeding, respiratory failure, renal failure, wound healing complications, and aneurysm-related mortality.

RESULTS

Stent grafts were successfully delivered and deployed in 129 of 133 patients (97.0%). At 30 days, a lower rate of mortality was observed in the TEVAR arm (5.3% vs 10.0%; P = .230), and TEVAR was associated with a significantly lower rate of MAEs (20.3% vs 48.3%; P < .001), primarily driven by a lower frequency of respiratory failure in the cohort (5.5% vs 21.6%; P = .007) and procedural bleeding. Freedom from aneurysm-related mortality through 5 years was similar at 91.3% for the TEVAR cohort and 89.4% for the surgical cohort (P = .406); with 5-year freedom from all-cause mortality at 57.1% and 50.2% (P = .289), respectively. Freedom from MAEs through 5 years was significantly higher in the TEVAR cohort (65.7% vs 44.7%; P = .001). Six TEVAR patients (4.5%) experienced core laboratory-reported type I or III endoleaks, and secondary procedures were performed in 10 patients (7.5%), with seven procedures to correct endoleak and one surgical conversion. Endograft migration occurred in three patients (2.3%) and wireform fractures were assessed in two patients (1.5%). Aneurysm sac size decreased or remained stable in 113 patients (85.0%) over 5-year follow-up. There were no instances of rupture or endograft occlusion. A 38-subject subset treated with the newer Relay Plus Delivery System had a significantly reduced MAE rate (15.8% vs 35.8%; P = .035), and fewer perioperative strokes (2.6% vs 12.6%; P = .108).

CONCLUSIONS

Data from the Relay TEVAR clinical trial demonstrate safety and effectiveness of the Relay device compared with surgical controls, indicating continued device durability with a low rate of device-related complications through 5 years.