A Twenty Year Experience with Thoracic Endovascular Aortic Repair
Himanshu J Patel*, David M Williams*, Narasimham L Dasika*, Joseph L Drews*, G Michael Deeb
University of Michigan Cardiovascular Center, Ann Arbor, MI
Endovascular approaches(TEVAR) have revolutionized treatment for thoracic aortic disease. We report our 20-year experience with this therapy.
383 patients(mean age 68.9 years, 54% male) underwent TEVAR(1993-2013), predominantly for fusiform aneurysm(125), saccular aneurysm/ulcer(128), acute(59) or chronic(34) dissection, or traumatic injury(35). Rupture was present in 79(20.6%). 80.3% were high risk for open repair. Mean aortic diameter was 5.5 cm. Extent of repair included arch in 205, total descending aorta in 180, and thoracoabdominal aorta(TAAA) in 20..
30-day mortality occurred in 18(4.7%). Neurologic events included stroke (5.5%) and spinal cord ischemia(permanent 1.1%, temporary 8.1%). Though dialysis was only required in 1.6%, 19% had renal failure by RIFLE criteria, which independently predicted early mortality(p=0.004, OR 4.2). 15-year survival was 34.3%. Advancing age, presence of CAD, COPD, TAAA, larger aortic diameter, rupture, or postoperative RIFLE class I or F all independently predicted late mortality (p<0.05). Endoleak occurred in 26.1%. 15-year freedom from dissection, rupture or reintervention in treated or adjacent aortic segments(i.e. treatment failure) was 69.0%. Independent predictors included presentation with rupture, larger aortic diameter, or intervention on the arch aorta(all p<0.03). Aortic pathology also independently predicted treatment failure(p=0.054, Figure).
TEVAR can be performed with acceptable results in a high risk population. Modification of devices specifically to treat the arch aorta or high risk pathology such as acute or chronic dissection may improve late treatment efficacy .
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