Objective: Endovascular repair in patients with connective tissue disorders (CTD) is controversial given concerns of durability. We describe characteristics and outcomes following TEVAR in patients with CTDs.
Methods: All patients undergoing TEVAR from 2010-2023 in the VQI were categorized as having a CTD or not. Demographics, baseline, and procedural characteristics were compared among groups. Multivariable logistic regression was used to evaluate the independent association of CTD with postoperative outcomes. Kaplan-Meier methods and multivariable Cox-regression analyses were used to evaluate 5-year survival and 3-year reinterventions.
Results: Of 17,422 patients, 261 had CTD (87% Marfan; 8% Loeys-Dietz; and 5% Ehlers-Danlos). Compared with no-CTD, CTD patients were younger (50y vs. 70y), more likely had acute dissection (30% vs. 18%), post-dissection aneurysm (44% vs 17%), symptomatic presentation (53% vs. 39%), and less likely degenerative aneurysms (19% vs. 47%) or PAU [+ IMH] (3% vs. 13%) (all p<.001). CTD patients were more likely to have prior repair of the ascending aorta/arch (open: 51% vs. 10%; endovascular 6% vs. 2%) or the descending aorta (open: 11% vs. 2%; endovascular 9% vs. 3%). No significant differences were found in abdominal suprarenal repairs, however, CTD patients had higher prior open infrarenal repair (5% vs. 3%), but lower prior endovascular infrarenal repair (4% vs. 5%)(all p<0.05). CTD was not significantly associated with perioperative mortality (3.8% vs. 7.1%; aOR:0.88 [95%CI 0.39-1.71];p=.73), any in-hospital complication (aOR:1.18 [0.85-1.60];p=.31), or in-hospital reintervention (aOR:1.29 [0.84-1.91];p=.22) compared with no-CTD. However, CTD patients had higher likelihood of transfusion (≥2PRBC: 33% vs. 30%; aOR:1.42 [1.05-
1.90];p=.028) and vasopressors (33% vs. 27%; aOR:1.44 [1.08-1.91];p=.011). 3-year reintervention rates were higher in CTD patients (31% vs. 17%; aHR:2.08 [1.38-3.15];p<.001), but 5-year survival was similar (86% vs. 79%; aHR:1.18 [0.74-1.87];p=0.47).
Conclusions: TEVAR for CTD patients appeared to be initially safe with similar odds for in-hospital complications, in-hospital reinterventions, and perioperative mortality, as well as similar hazards for 5-year mortality compared with no-CTD patients. However, CTD patients had higher 3-year reintervention rates. Future studies should assess long-term durability after TEVAR compared with the recommended open repair to appropriately weigh risks and benefits of endovascular treatment in CTD patients.
| Prior Surgical History | ||||||
| No CTD | CTD | |||||
| (N=17161) | (N=261) | P-value | ||||
| Prior Aortic Surgery | ||||||
| None | 74% | 29.5% | <.001 | |||
| Open | 15% | 52% | ||||
| Endovascular | 8.9% | 10% | ||||
| Both | 1.6% | 6.5% | ||||
| Prior open surgery location | ||||||
| Ascending/arch | 10% | 51% | <.001 | |||
| Descending thoracic | 1.9% | 11.5% | .013 | |||
| Suprarenal | 0.9% | 2.3% | .39 | |||
| Infrarenal | 3.2% | 4.6% | <.001 | |||
| Prior endovascular surgery location | ||||||
| Ascending/arch | 2% | 5.7% | .037 | |||
| Descending thoracic | 3.4% | 9.2% | .008 | |||
| Suprarenal | 0.8% | 2.7% | .11 | |||
| Infrarenal | 5.3% | 3.8% | <.001 | |||
| Perioperative outcomes | ||||||
| No CTD | CTD | CTD vs. no CTD | ||||
| (N=17161) | (N=261) | P-value | aOR* | 95% CI | P-value | |
| Perioperative death | 7.1% | 3.8% | 0.053 | 0.88 | 0.39-1.71 | 0.73 |
| Stroke | 3.6% | 2.3% | 0.35 | 0.66 | 0.23-1.48 | 0.37 |
| Spinal cord ischemia | 3.3% | 2.7% | 0.59 | 0.79 | 0.31-1.67 | 0.58 |
| AKI | 11% | 10% | 0.31 | 0.98 | 0.61-1.50 | 0.94 |
| Postoperative dialysis | 2.7% | 2.3% | 0.72 | 0.93 | 0.32-2.10 | 0.89 |
| Myocardial infarction | 2.1% | 0.4% | 0.09 | 0.31 | 0.02-1.41 | 0.24 |
| Pulmonary complications | 8.1% | 6.5% | 0.41 | 0.99 | 0.56-1.63 | 0.98 |
| Postoperative transfusion | 23% | 26% | 0.19 | 1.4 | 1.03-1.95 | 0.028 |
| Any complication† | 23% | 26% | 0.91 | 1.1 | 0.85-1.60 | 0.31 |
| Postoperative spinal drain | 3.6% | 6.1% | 0.09 | 1.5 | 0.82-2.60 | 0.15 |
| Postoperative vasopressors | 27% | 33% | 0.039 | 1.4 | 1.08-1.90 | 0.011 |
| In-hospital reinterventions | 8.3% | 14% | 0.002 | 1.3 | 0.82-1.90 | 0.22 |
| ICU length of stay, days | 2 [1-4] | 3 [2-5] | 0.10 | - | - | - |
| Total length of stay, days | 4 [2-8] | 6 [4-11] | 0.051 | - | - | - |
| Follow up | ||||||
| No CTD | CTD | CTD vs. no CTD | ||||
| (N=11756) | (N=200) | P-value | aHR | 95% CI | P-value | |
| 5-year survival | 79% | 86% | 0.11 | 1.18 | 0.74-1.87 | 0.47 |
| (N=8687) | (N=151) | |||||
| 3-year reinterventions | 17% | 31% | <.001 | 2.08 | 1.38-3.15 | <.001 |
| Data are presented as median [interquartile range] for continuous measures, and frequencies and percentages for categorical measures.† Any complication was defined as the presence of any of the following during index hospitalization: pulmonary complication, cardiac complication, acute kidney injury (AKI), new dialysis, stroke, intestinal ischemia, leg ischemia, or reoperation. * Multivariable models adjusted for baseline pathology, age, gender, aortic diameter, BMI, race, prior diabetes, prior renal dysfunction | ||||||
