Endovascular Treatment of Ruptured Thoracic Aortic Aneurysm in Patients Older than 75 Years

AbstractObjectivesTo investigate the outcomes of thoracic endovascular aortic repair (TEVAR) for ruptured descending thoracic aortic aneurysm (rDTAA) in patients older than 75 years.MethodsWe retrospectively identified all patients treated with TEVAR for rDTAA at seven referral centres between 2002 and 2009. The cohort was stratified according to age ≤75 and >75 years, and the outcomes after TEVAR were compared between both groups.ResultsNinety-two patients were identified of which 73% (n = 67) were ≤75 years, and 27% (n = 25) were older than 75 years. The 30-day mortality was 32.0% in patients older than 75 years, and 13.4% in the remaining patients (p = 0.041). Patients older than 75 years suffered more frequently from postoperative stroke (24.0% vs. 1.5%, p = 0.001) and pulmonary complications (40.0% vs. 9.0%, p = 0.001). The aneurysm-related survival after 2 years was 52.1% for patients >75 years, and 83.9% for patients ≤75 years (p = 0.006).ConclusionsEndovascular treatment of rDTAA in patients older than 75 years is associated with an inferior outcome compared with patients younger than 75 years. However, the mortality and morbidity rates in patients above 75 years are still acceptable. These results may indicate that endovascular treatment for patients older than 75 years with rDTAA is worthwhile

Thoracic aortic catastrophes : towards the endovascular solution

Descending thoracic aortic catastrophes include a variety of acute pathologies of the descending thoracic aorta, which are all associated with high morbidity and mortality rates, requiring immediate intervention. For this thesis, we explored the management and outcomes of several thoracic aortic catastrophes, including traumatic thoracic aortic injury, ruptured descending thoracic aortic aneurysm, acute type B aortic dissection, and aortobronchial and aortoesophageal fistulas. Open surgical repair has been the traditional treatment of these thoracic aortic catastrophes but thoracic endovascular aortic repair (TEVAR) recently offers a less invasive alternative for the management of thoracic aortic disease. Our studies showed that TEVAR for ruptured descending thoracic aortic aneurysms and traumatic thoracic aortic injuries significantly reduced the short-term morbidity and mortality rates compared with traditional open surgery. Endovascular repair of ruptured descending thoracic aortic aneurysms was however associated with a considerable incidence of peri-procedural stroke as well. In a different study we found that elderly patients were at increased risk for stroke, while the incidence of stroke has decreased over the years. The optimal management of acute type B aortic dissection, another aortic catastrophe, mainly depends on the presentation of the patient. We found that definitive medical management of uncomplicated acute type B aortic dissection is associated with low in-hospital mortality, however, those patients with recurrent pain or refractory hypertension have a much higher mortality rate. An aortic intervention is generally indicated if acute type B aortic dissection is associated with complications, such as acute renal failure, visceral ischemia, limb ischemia, paraplegia, or aortic rupture. Advanced age appeared to be a strong risk factor for mortality among patients with complicated acute type B aortic dissection, irrespective of the management type. For patients with aortobronchial fistulas, TEVAR appeared as a definite treatment, associated with lower mortality compared with traditional results of open surgery. After TEVAR for aortoesophageal fistulas, however, additional esophageal surgery was often needed to treat the fistula. In a meta-analysis of the literature, we found that patients with aortoesophageal fistulas that did not undergo esophageal repair after TEVAR had a significantly increased mortality rate during follow-up, primarily due to infective complications from the persistent connection with the esophagus. TEVAR of thoracic aortic catastrophes is still associated with considerable rates of endograft-related complications during follow-up, such as endoleak in 5% to 30. Thoracic aortic catastrophes are often associated with considerable blood loss and hypovolemic shock. We studied the impact of hypovolemia on the aortic dimensions, and the potential implications for the endovascular management of acute thoracic aortic disease. In an experimental porcine model and in a study of hemodynamically unstable trauma patients, we found that the aortic dimensions could decrease during hypovolemic shock. This could result in undersizing of the endograft using the pre-operative CT scan and a subsequently increased risk of endoleaks. Therefore, increased oversizing of the endograft or additional aortic imaging after fluid resuscitation for more adequate aortic measurements may be required in hypovolemic patients with acute thoracic aortic disease requiring TEVAR

Meta-analysis of open versus endovascular repair for ruptured descending thoracic aortic aneurysm

Introduction: Ruptured descending thoracic aortic aneurysm (rDTAA) is associated with high mortality rates. Data supporting endovascular thoracic aortic aneurysm repair (TEVAR) to reduce mortality compared with open repair are limited to small series. We investigated published reports for contemporary outcomes of open and endovascular repair of rDTAA. Methods: We systematically reviewed all studies describing the outcomes of rDTAA treated with open repair or TEVAR since 1995 using MEDLINE, Cochrane Library CENTRAL, and Excerpta Medica Database (EMBASE) databases. Case reports or studies published before 1995 were excluded. All articles were critically appraised for relevance, validity, and availability of data regarding treatment outcomes. All data were systematically pooled, and meta-analyses were performed to investigate 30-day mortality, myocardial infarction, stroke, and paraplegia rates after both types of repair. Results: Original data of 224 patients (70% male) with rDTAA were identified: 143 (64%) were treated with TEVAR and 81 (36%) with open repair. Mean age was 70 \ub1 5.6 years. The 30-day mortality was 19% for patients treated with TEVAR for rDTAA compared 33% for patients treated with open repair, which was significant (odds ratio [OR], 2.15, P = .016). The 30-day occurrence rates of myocardial infarction (11.1% vs 3.5%; OR, 3.70, P < .05), stroke (10.2% vs 4.1%; OR, 2.67; P = .117), and paraplegia (5.5% vs 3.1%; OR, 1.83; P = .405) were increased after open repair vs TEVAR, but this failed to reach statistical significance for stroke and paraplegia. Five additional patients in the TEVAR group died of aneurysm-related causes after 30 days, during a median follow-up of 17 \ub1 10 months. Follow-up data after open repair were insufficient. The estimated aneurysm-related survival at 3 years after TEVAR was 70.6%. Conclusion: Endovascular repair of rDTAA is associated with a significantly lower 30-day mortality rate compared with open surgical repair. TEVAR was associated with a considerable number of aneurysm-related deaths during follow-up

Predicting aortic enlargement in type B aortic dissection

Patients with uncomplicated acute type B aortic dissection (ABAD) can generally be treated with conservative medical management. However, these patients may develop aortic enlargement during follow-up, with the risk of rupture. Several predictors have been studied in recent years to identify ABAD patients at high risk of aortic enlargement, who may benefit from early surgical or endovascular intervention. This study reviewed and summarized the current available literature on prognostic variables related to aortic enlargement during follow-up in uncomplicated ABAD patients. It revealed multiple factors affecting aortic expansion including demographic, clinical, pharmacologic and radiologic variables. Such predictors may be used to identify those ABAD patients at higher risk for aortic enlargement who may benefit from closer radiologic surveillance or early endovascular intervention. This approach deserves even more consideration because a significant number of patients develop aneurysmal degeneration along the dissected segments during follow-up, and may lose the opportunity for endovascular treatment if not identified at an early stage

Predictors of aortic growth in uncomplicated type B aortic dissection

Background Patients with uncomplicated acute type B aortic dissection (ABAD) generally can be treated with conservative medical management. However, these patients may develop aortic enlargement during follow-up, with the risk for rupture, which necessitates intervention. Several predictors have been studied in recent years to identify ABAD patients at high risk for aortic enlargement who may benefit from early surgical or endovascular intervention. This study systematically reviewed and summarized the current available literature on prognostic variables related to aortic enlargement during follow-up in uncomplicated ABAD patients. Methods Studies were included if they reported predictors of aortic growth in uncomplicated ABAD patients. Studies about type A aortic dissection, aortic aneurysm, intramural hematoma, or ABAD that required acute intervention were excluded. Results A total of 18 full-text articles were selected. The following predictors of aortic growth in ABAD patients were identified: age <60 years, white race, Marfan syndrome, high fibrinogen-fibrin degradation product level ( 6520 \u3bcg/mL) at admission, aortic diameter 6540 mm on initial imaging, proximal descending thoracic aorta false lumen (FL) diameter 6522 mm, elliptic formation of the true lumen, patent FL, partially thrombosed FL, saccular formation of the FL, presence of one entry tear, large entry tear ( 6510 mm) located in the proximal part of the dissection, FL located at the inner aortic curvature, fusiform dilated proximal descending aorta, and areas with ulcer-like projections. Tight heart rate control (<60 beats/min), use of calcium-channel blockers, thrombosed FL, two or more entry tears, FL located at the outer aortic curvature, and circular configuration of the true lumen were associated with negative or limited aortic growth. Conclusions Several predictors might be used to identify those ABAD patients at high risk for aortic growth. Although conservative management remains indicated in uncomplicated ABAD, these patients might benefit from closer follow-up or early endovascular intervention

Endovascular repair of ruptured thoracic aortic aneurysms: predictors of procedure-related stroke

Background: Thoracic endovascular aortic repair (TEVAR) is a valuable tool in the treatment of ruptured descending thoracic aortic aneurysm (rDTAA). A major complication of this procedure is stroke. We investigated the incidence and risk factors for stroke after TEVAR for rDTAA. Methods: We retrospectively evaluated the outcomes of all patients who were treated with TEVAR for rDTAA at seven institutions between 2002 and 2009. A total of 92 patients were identified, with a mean age of 69.4 \ub1 11 years and 67% were men. Multivariable logistic regression analysis was used to investigate risk factors for stroke, including demographics, comorbidities, aneurysm, and procedural details. Results: The 30-day mortality was 17.4% (n = 16), and 7.6% (n = 7) suffered from procedure-related stroke. Four of seven patients with stroke (57.1%) expired within 30 days, compared with 12 (14.1%) of the patients without stroke (OR, 8.11; p = .004). In multivariable regression analysis, increasing age was associated with an increased risk of stroke (OR, 1.38; 95% CI, 1.08-1.76; p = .010), whereas more recent procedures were associated with a reduced risk of stroke (OR, 0.52; 95% CI, 0.28-0.97; p = .039). The aneurysm-related survival at 1 year after TEVAR was 42.9% for patients who suffered from stroke, and 77.6% for those without stroke (p = .006). Conclusions: Endovascular repair of rDTAA is associated with a considerable risk of stroke, and stroke is an important cause of 30-day mortality in this patient group. Particularly older patients are at risk for developing stroke after endovascular repair of rDTAA. The risk of stroke decreased significantly over time in this evaluation

Morphologic predictors of aortic dilatation in type B aortic dissection

Background: Conservative management of acute type B aortic dissection (ABAD) is often associated with aortic dilatation during follow-up increasing the risk of aortic rupture. The goal of this study was to investigate whether morphologic characteristics of the dissection can predict aortic growth. Methods: All conservatively managed ABAD patients from four referral centers were included (2000 to 2010). Aortic diameters were measured at five levels at baseline and at the last follow-up computed tomography angiography, and annual aortic growth rates were calculated for all segments. Linear regression was used to study the influence of aortic morphologic characteristics for aortic dilatation. Results: Included were 62 patients (41 men) with a mean age of 60.3 \ub1 10.7 years. Among the 310 analyzed aortic segments, 248 (80.0%) were dissected, of which 211 (85.1%) showed aortic growth. Overall, the mean diameter increased from 36.1 \ub1 9.4 to 40.2 \ub1 11.1 mm (P <.01), which corresponds with a mean aortic growth rate of 3.1 \ub1 6.3 mm/y. Multivariate linear regression analysis showed that male sex (95% confidence interval [CI], 0.60-4.04; P =.005) and a saccular false lumen (95% CI, 2.07-7.81: P =.001) were associated with a significantly increased aortic growth rate. Increasing age (95% CI, -0.23 to -0.04; P =.005), increased number of entry tears (95% CI, -2.40 to -0.43; P =.005), false lumen located on the aortic outer curvature (95% CI, -4.30 to -0.38; P =.019), and a circular configuration of the true lumen (95% CI, -5.35 to -0.32; P =.027) were associated with a decreased aortic growth rate. Conclusions: Multiple morphologic characteristics appear to predict aortic dilatation in ABAD patients treated medically. Early assessment of these morphologic signs may be useful in the selection of ABAD patients who might benefit from closer radiologic surveillance or prophylactic intervention

Predictors of false lumen thrombosis in type B aortic dissection treated with TEVAR

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) offers a less invasive treatment option in type B aortic dissection (TBAD) patients and its value has been demonstrated in acute and chronic dissection patients. Total false lumen thrombosis (FLT) is associated with better long-term outcome in these patients, however, this is not obtained in all patients. The purpose of this study was to investigate predictors of FLT. METHODS: We retrospectively investigated patients who underwent TEVAR for a type B dissection in a large referral center between 2005 and 2012. All patients with a CT angiogram (CTA) obtained preoperatively, postoperatively and after one year of follow-up were selected for analysis. Volume measurements and several morphologic characteristics were analyzed for all scans using Aquarius iNtuition software (TeraRecon, San Mateo, Calif, USA). Multivariate logistic regression analyses were used to study the influence of these characteristics on FLT. RESULTS: Of 132 patients that received TEVAR for an aortic dissection, 43 patients (mean age, 60.3\ub114.2; 30 male) met our inclusion criteria, of whom 16 (37%) developed full FLT after 1 yr of follow-up. Multivariate logistic regression showed that side branch involvement [odds ratio (OR), 0.03; 95% confidence interval (CI), 0.00-0.92; P=0.045] and a total patent false lumen (FL) at presentation (OR, 0.01; 95% CI, 0.00-0.58; P=0.027) were associated with decreased complete FLT. Volumetric data showed significantly more reduction of the thoracic false lumen in FLT patients compared with non-FLT (-52.3% vs. -32.4%; P=0.043) and also a tendency of less volume increase in the abdominal segment (-5.0\ub137.5 vs. 21.8\ub144.3; P=0.052). CONCLUSIONS: Patients admitted with type B dissection and branch vessel involvement or a patent entry tear after TEVAR are less likely to develop FLT and aortic remodeling during follow-up. These findings suggest that these patients may require a more extensive procedure and more intensive follow-up to prevent long-term complications