Comparison of Outcomes in Thoracic Endovascular Aneurysm Repair (TEVAR) for Aortic Dissection and Aortic Aneurysm
Jinny J. Lu, MD, Darshan Patel, BS, Sara Zettervall, MD, Kyongjune Benjamin Lee, MD, Richard Amdur, PhD, Anton Sidawy, MD, Robyn Macsata, MD, Bao-Ngoc Nguyen, MD.
George Washington University, Washington, DC, USA.
Objective: Thoracic endovascular aortic repair (TEVAR) for aortic dissection (DISSECTION) is often associated with worse outcomes compared to TEVAR for aortic aneurysms (ANEURYSM). This study evaluates the underlying factors of this association and identifies predictors of post-operative mortality and morbidities for DISSECTION.
Methods: We utilized the ACS-NSQIP database to identify all patients undergoing TEVAR from 2012 to 2015 and stratified them into DISSECTION and ANEURYSM based on the ICD-9/ICD-10 codes. 30-day mortality and cardiac, pulmonary, renal, and wound complications were analyzed. Chi-square, Fisher Exact Test, Wilcoxon Two-Sample Test, Kruskal-Wallis Test and multivariate regression models were used for data analysis.
Results: 2453 patients were identified: 1527 patients were ANEURYSM and 926 patients were DISSECTION. DISSECTION patients were more likely to be male, active smokers and obese whereas ANEURYSM patients were more likely to be diabetic and have COPD. An overwhelmingly high percentage of DISSECTION was emergent compared to ANEURYSM (33% vs 7%, p=<0.01). In the univariate analysis, DISSECTION had significantly higher 30-day mortality, cardiac, pulmonary, and renal complications. However, multivariate analysis revealed that only mortality and pulmonary complications remained statistically significant in DISSECTION compared to ANEURYSM. Analysis of the underlying factors for worse outcomes of DISSECTION suggested that emergency status was the strongest predictor of 30-day mortality and composite outcomes (OR 2.52 [1.94-3.28]). Interestingly, subgroup analysis excluding all emergent cases revealed no significant difference in 30-day mortality and morbidities between DISSECTION and ANEURYSM, except for pulmonary complications that were significantly increased in the Dissection group.
Conclusions: TEVAR for aortic dissection has worse outcomes compared to TEVAR for aneurysms mostly because this procedure in DISSECTION is often performed emergently. These data suggest that unless TEVAR for DISSECTION is performed for true emergent indications such as tissue malperfusion or impending rupture, it should be delayed if possible to be done in a more elective setting.
Table: 30-day outcomes of TEVAR for ANEURYSM vs. DISSECTION.
| All TEVARs | Non-Emergent TEVARs | |||||||
| Aneursym (n=1527) | Dissection (n=926) | OR | p | Aneurysm (n=1427) | Dissection (n=623) | OR | p | |
| Mortality | 70 (5%) | 76 (8%) | 1.68 [1.12-2.53] | 0.01 | 58 (4%) | 30 (5%) | 1.55 [0.95-2.51] | 0.08 |
| Return to OR | 125 (8%) | 119 (13%) | 1.28 [0.94-1.74] | 0.12 | 109 (8%) | 59 (10%) | 1.37 [0.95-1.97] | 0.09 |
| Cardiac | 48 (3%) | 46 (5%) | 1.10 [0.66-1.83] | 0.71 | 39 (3%) | 15 (2%) | 0.93 [0.50-1.74] | 0.83 |
| Pulmonary | 144 (9%) | 165 (18%) | 1.56 [1.16-2.11] | <0.01 | 121 (9%) | 73 (12%) | 1.43 [1.01-2.01] | 0.04 |
| Renal | 27 (2%) | 43 (5%) | 1.54 [0.84-2.82] | 0.16 | 22 (2%) | 11 (2%) | 1.15 [0.54-2.42] | 0.72 |
| Sepsis | 59 (4%) | 51 (6%) | 0.96 [0.62-1.49] | 0.87 | 52 (4%) | 20 (3%) | 1.01 [0.57-1.76] | 0.99 |
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