Contemporary Outcomes Of TEVAR For Ruptured Versus Intact Descending Thoracic Aortic Aneurysms: Analysis From The Vascular Quality Initiative
Cassra Arbabi, MD1, Isaac Naazie, MD, MPH2, Mahmoud Malas, MD, MHS2, Alessandra Rivera, DrPH1, Aamir Shah, MD1, NavYash Gupta, MD1, Ali Azizzadeh, MD1.
1Cedars-Sinai Medical Center, Los Angeles, CA, USA, 2University of California, San Diego, La Jolla, CA, USA.
OBJECTIVES: Thoracic endovascular aortic repair (TEVAR) is the primary treatment for descending thoracic aortic aneurysms (DTAA). We aim to determine the contemporary outcomes of TEVAR for patients with intact (i) or ruptured (r) DTAA.
METHODS: We analyzed Vascular Quality Initiative data on all patients ≥18 years who underwent TEVAR for iDTAA or rDTAA from 2014 to 2020. Primary outcomes included 30-day and 1-year mortality. Secondary outcomes included in-hospital death, perioperative stroke, spinal cord ischemia (SCI), reintervention and hospital length of stay (LOS). Proximal landing zone < 3 was a surrogate for coverage of the left subclavian artery (LSCA).
RESULTS: Among 1,459 patients (median age 73, 50% female) who underwent TEVAR, 1,344 (92%) had iDTAA and 115 (8%) had a rDTAA. There was no significant difference in baseline co-morbidities, except patients with iDTAA were more likely to have a smoking history and prior aneurysm repair. Patients with rDTAA had a significantly higher mortality at 30-days (21.7% vs 3.1%; p < 0.001) and 1- year (36.7% vs 11.3%; p < 0.001) and had higher rates of reintervention (13% vs 5.2%; p = 0.001), LOS (median, 9 vs 4 days; p < 0.001) and in-hospital death (19.1% vs 2.8%; p < 0.001). The overall rate of post-operative complications was higher in rDTAA (53.5% vs 19.4%; p < 0.001), with significantly higher rates of stroke (9.7% vs 2.3%; p < 0.001), SCI (10.5% vs 2.3%; p < 0.001) and respiratory complications (29.8% vs 5.4%; p <0.001). After adjustment, there was a nearly nine-fold increase in the odds of 30-day mortality (OR 8.92; p <0.001), and five-fold increase in the risk of 1-year mortality (HR 4.78; p <0.001) in patients with rDTAA. In patients with iDTAA, the independent predictors of 30-day mortality were age >75 and coverage of LSCA, while age > 75, ESRD, distal landing zone > 5 and prior PCI or CABG were predictive of 1-year mortality. Among patients with rDTAA, prior non-cardiac bypass and prior PCI or CABG were independently predictive of 30-day and 1-year mortality, respectively.
CONCLUSIONS: Contemporary outcomes of TEVAR for DTAA show significantly increased mortality for rDTAA compared to iDTAA. LSCA coverage is a significant predictor of short-term mortality for patients with iDTAA. This data supports efforts to screen for and electively repair DTAA.
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