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Purpose: Morbidity and mortality have improved with the evolution of endovascular techniques (TEVAR) for thoracic aortic pathology, but results after aortic intervention in patients with end-stage renal disease remain unclear. The objective of this study is to evaluate outcomes of open and endovascular descending thoracic aortic repair in dialysis-dependent patients.
Methods: We identified 352 patients with preexisting end-stage renal disease (ESRD) on dialysis undergoing open repair (n=136) or TEVAR (n=216) of the thoracic aorta from 2005-08 using the United States Renal Data System database. Acute presentation was defined as ruptured aneurysm, dissection, or traumatic injury; all other interventions were considered elective. Endpoints were 30-day mortality, overall survival, rates of perioperative complications, and procedural trends over time. Between-group comparisons and survival analysis utilized standard statistical methods. Logistic and Cox regression were performed using multivariate analysis.
Results: TEVAR subjects were older than those undergoing open repair (68.2±11.5yr vs. 60.8±13.2, p<0.001); no other demographics differed. 303 patients had thoracic or thoracoabdominal aneurysms; 47 (13.4%) were ruptured on presentation. 44 (12.5%) had aortic dissection and 5 (1.4%) aortic trauma. Overall 30-day mortality was 21.3% (n=75) and greater for open repair (n=41, 30.1%) than TEVAR (n=34, 15.7%; p=0.002). Elective 30-day open mortality (n=27, 29.3%) was also greater than TEVAR (n=24, 14.3%; p=0.005). Those with acute presentation trended toward higher mortality for open repair (n=14, 31.8% vs. n=10, 15.7%; p=0.17). Respiratory failure was higher for open (n=69, 50.7% vs n=56, 25.9%; p<0.001); postoperative stroke was higher with TEVAR (n=21,9.7% vs n<10,<7%; p=0.02). Estimated 1-year survival was 50% and did not differ between groups (44% open, 53% TEVAR). In multivariate analysis, TEVAR decreased odds of 30-day mortality compared to open (OR 0.41, 95% CI 0.24-0.71) but failed to demonstrate long-term survival advantage.
Conclusions: In ESRD patients, TEVAR provides short-term mortality benefits compared to open repair but long-term mortality remains high regardless of treatment modality. Elective intervention for thoracic aortic pathology in this population remains high risk and should be approached with caution.