Optimal Graft Sizing, Treatment of Endoleaks Improve Survival After TEVAR for Descending Thoracic Aortic Aneurysms
Key findings
- This retrospective review of a prospective database examined long-term outcomes of 219 patients who underwent thoracic endovascular aneurysm repair for descending thoracic aortic aneurysms
- The unadjusted three-year survival rate was 78%
- 80% of patients demonstrated aneurysm sac stability/regression and had a clear survival advantage over those who had sac growth
- Endoleaks and inappropriate graft sizing also increased the risk of mortality
- The optimal graft size appears to be 20% to 30% of the proximal landing zone measurement
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The number of centers performing thoracic endovascular aneurysm repair (TEVAR) for descending thoracic aortic aneurysms (DTAA) nearly tripled between 2000 and 2010. However, most studies of TEVAR for this indication have been limited to short-term outcomes of 30 days.
In an institutional retrospective review, Adam Tanious, MD, MMSc, clinical fellow in Surgery, Mark F. Conrad, MD, MMSc, director of Clinical Research in the Division of Vascular and Endovascular Surgery at Massachusetts General Hospital, and colleagues determined predictors of three-year survival after TEVAR for DTAA. They published their findings in the Journal of Vascular Surgery.
Study Details
At Mass General, all patients who undergo a thoracic aortic procedure are tracked in a prospective database. 219 patients, average age 74, underwent TEVAR for DTAA between January 2004 and January 2018. The average follow-up period was three years (range, 0.5–5).
Primary Outcomes
- Aneurysm sac regression/stability: 80% of patients
- Three-year survival rate: 78%
- Reintervention rate: 9%
Secondary Outcomes
- Endoleak: 23%
- Overall complication rate: 55%
- Neurologic complication rate: 16%
Predictors
The three-year survival rate was 88% for patients with aneurysm sac stability/regression versus 70% for those with sac growth (P = 0.04). Predictors of sac growth included endoleak (OR, 65) and graft oversizing <20% (OR, 15).
The only protective factor for mortality was graft oversizing (HR, <0.001 for every 1% increase at proximal landing zone; P = .03). On the other hand, patients with graft oversizing >30% had an increased risk of mortality (HR, >10; P = .049).
Other factors significantly increased mortality risk:
- Endoleak (HR, 3.6; P = .03)
- Diabetes (HR, 4.1; P = .048)
- Age (HR, 1.2 for every 1-year increase; P = .002)
- Year of surgery (HR, 1.3 for every year after 2004; P = .01)
- Peripheral artery disease (HR, 5.2; P = .04)
Recommendations to Surgeons
Three measures should improve mid- and long-term outcomes for patients undergoing TEVAR for DTAA: appropriate graft sizing, treatment of endoleaks and rigorous surveillance to prevent future aortic events through reintervention. Optimal graft sizing appears to be 20% to 30% of the proximal landing zone measurement.
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