Trends And Outcomes Of TEVAR With Cervical Debranching
Kirthi S. Bellamkonda, MSc, Sameh Yousef, MD, Naiem Nassiri, MD, Alan Dardik, MD, PhD, Raul Guzman, MD, Arnar Geirsson, MD, Cassius I. Ochoa Chaar, MD.
Yale University School of Medicine, New Haven, CT, USA.
Objective:
TEVAR has become the preferred surgery for pathology of the descending thoracic aorta. Cervical debranching in the form of carotid-subclavian bypass or transposition (CSBT) and carotid-carotid bypass (CCB) enables the use of TEVAR for treatment of more complex anatomy involving the arch. This study examines the impact of concomitant cervical bypasses on the perioperative outcomes of TEVAR.
Methods:
ACS-NSQIP files (2005-2017) were reviewed. Based on CPT codes, all patients undergoing TEVAR were identified and divided into 3 groups: TEVAR, TEVAR with 1 bypass (CSBT or CCB), and TEVAR with 2 bypasses (CSBT and CCB). Patient characteristics and peri-operative outcomes of the 3 groups were compared. Multivariable analysis was performed to determine factors associated with mortality.
Results:
There were 3,291 TEVAR and 10% had concomitant debranching (1 bypass = 9%, 2 bypasses = 1%). The frequency of debranching increased from 3.4% to 10.9% (P =.01) during the study period. There were significant differences between the 3 groups in sex, age, smoking, urgency of surgery, and anesthesia technique. Patients undergoing TEVAR with cervical debranching had significantly higher morbidity, longer operating time, and longer hospital stay compared to TEVAR alone. The mortality of TEVAR with 2 bypasses (22.6%) was significantly higher than TEVAR alone (7.5%), and TEVAR with 1 bypass (6.8%) (P<.01). A subgroup analysis of cases of TEVAR with 1 bypass showed no significant difference in mortality between TEVAR+CSBP (6.5%) vs TEVAR+CCB (8.8%) (P=.61). Multivariable analysis showed that TEVAR with 2 bypasses was associated with significantly increased mortality compared to TEVAR alone (OR = 0.23 [CI 0.09-0.57]) and TEVAR with 1 bypass (OR = 3.5 [1.27-9.71]). Age (OR = 1.74 [1.42-2.13]), dependent functional status (OR = 1.48 [1.00-2.19]), dialysis (OR = 2.61 [1.57-4.33]), and emergent status (OR = 3.65 [2.72-4.89]) were also associated with mortality.
Conclusion:
TEVAR with concomitant cervical debranching is being increasingly used to treat complex aortic pathology and is associated with significantly worse outcomes than TEVAR alone. As fenestrated endovascular technology to treat the aortic arch emerges, the outcomes of open surgical debranching in this study constitute an important benchmark for comparison.
Table 1. Baseline characteristics and outcomes
| TEVAR only N=2,979 (%) | TEVAR + 1 bypass N= 281 (%) | TEVAR + 2 bypasses N= 31 (%) | P | |||
| Demographics | Gender | Male | 1,692 (56.8)2 | 179 (63.7)1 | 15(48.4) | 0.050* |
| Age Groups | 18-64 | 863 (29)2 | 115(41)1 | 8(25.8) | <0.01* | |
| 65-80 | 1,442(48.4) | 122 (43.4) | 18 (58) | |||
| >80 | 662 (22.2) | 44 (15.7) | 5 (16.1) | |||
| Dependent Functional status | 252 (8.5) | 18 (6.4) | 2 (6.4) | 0.460 | ||
| Comorbidities | Diabetes Mellitus | 367 (12.3) | 35 (12.5) | 2 (6.4) | 0.609 | |
| Current smoker | 950 (31.9)2 | 68(24.2)1 | 12 (38.7) | 0.020* | ||
| History of severe COPD | 540 (18.1) | 44 (15.7) | 5 (16.1) | 0.570 | ||
| Congestive heart failure | 73 (2.4) | 6 (2.1) | 0 (0) | 0.640 | ||
| Hypertension | 2570 (86.3) | 234 (83.3) | 30 (96.8) | 0.080 | ||
| Dialysis | 113 (3.8) | 11 (3.9) | 2 (6.4) | 0.740 | ||
| Indication | Aneurysm | 1481 (49.7) | 135 (48) | 14 (45.2) | 0.430 | |
| Dissection | 664 (22.3) | 70 (24.9) | 8 (25.8) | |||
| Rupture | 207 (6.9) | 10 (3.6) | 2 (6.4) | |||
| Not specified | 627 (21) | 66 (23.5) | 7 (22.6) | |||
| Procedure details | Emergency case | 574 (19.3)2 | 34 (12.1)1 | 5 (16.1) | <0.01* | |
| Principal anesthesia technique | General | 2,827 (94.9)2 | 281 (100)1 | 31(100) | <0.01* | |
| Other | 152 (5.1) | 0 (0) | 0 (0) | |||
| ASA classification | ≤3 | 1493 (50.1) | 154 (54.8) | 12 (38.7) | 0.820 | |
| ≥4 | 1477 (49.6) | 127 (45.2) | 19 (61.3) | |||
| Total operation time, Mean ± SEM (minutes) | 151±22,3 | 265±71,3 | 342±181,2 | <0.01* | ||
| Outcomes | Unplanned intubation | 189 (6.3)3 | 21 (7.5)3 | 8 (25.8)1,2 | <0.01* | |
| Failed weaning from ventilator | 205 (6.9)3 | 22 (7.8)3 | 9 (29)1,2 | <0.01* | ||
| Cardiac arrest | 100 (3.4) | 12 (4.3) | 3 (9.7) | 0.123 | ||
| Bleeding | 583 (19.6)3 | 68 (24.2)3 | 15 (48.4)1,2 | <0.01* | ||
| Renal failure | 33 (1.1) | 1 (0.4) | 0 (0) | 0.410 | ||
| Sepsis | 130 (4.4) | 11 (3.9) | 2 (6.4) | 0.790 | ||
| Stroke | 90 (3)2,3 | 21 (7.5)1 | 4 (12.9)1 | <0.01* | ||
| Any morbidity | 1,177 (39.5)2,3 | 135 (48)1,3 | 24 (77.4)1,2 | <0.01* | ||
| Overall Mortality | 224 (7.5)3 | 19 (6.8)3 | 7 (22.6)1,2 | <0.01* | ||
| Re-admission | 30 (2.8) | 1 (1) | 1 (7.1) | 0.249 | ||
| Hospital length of stay Mean ± SEM (days) | 7.9 ± 0.2 | 9 ± 0.6 | 12.6 ± 2.3 | 0.492 | ||
| BMI= Body Mass Index, COPD= Chronic Obstructive Pulmonary Disease, ASA= American Society of Anesthesia, SEM= Standard Error of the Mean. *=Post hoc analysis showing statistical difference between the groups, TEVAR only 1, TEVAR + 1 bypass2, TEVAR + 2 bypasses3. | ||||||
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