Outcomes Of Staged Repairs Of Complex Endovascular Repairs Of Pararenal And Thoracoabdominal Aortic Aneurysms
Thomas FX O'Donnell, MD1, Kirsten D. Dansey, MD, MPH2, Virendra I. Patel, MD, MPH1, Sara L. Zettervall, MD, MPH2, Adam W. Beck, MD3, Marc L. Schermerhorn, MD4.
1Columbia University Irving Medical Center, New York, NY, USA, 2University of Washington, Seattle, WA, USA, 3University of Alabama at Birmingham, Birmingham, AL, USA, 4Beth Israel Deaconess Medical Center, Boston, MA, USA.
OBJECTIVES: Spinal cord ischemia (SCI) remains the Achille's heel of thoracoabdominal aortic aneurysm repair. Endovascular treatment allows for the staging of these repairs in an effort to decrease the risk of SCI, although data are limited.
METHODS: We studied all endovascular repairs of intact pararenal and thoracoabdominal aortic aneurysms in the VQI from 2014-2021 that incorporated at least one renal/visceral vessel. Propensity scores with inverse probability weighting were used to compare perioperative and long-term outcomes of staged and single-stage repairs. Extensive aneurysms were defined as Crawford types 1,2,3,5, or cases involving coverage of at least zone 4 to zone 9.
RESULTS: There were 3,398 repairs during the study period; 8.7% of all cases were staged with a median 45 day interval, but 21% of extensive aneurysms were staged. The most common staging method was staged thoracic endovascular aneurysm repair (TEVAR-71%), while 22% utilized staged branch vessel treatment and 17% involved staged iliac treatment. Staged repairs were more often employed by high volume surgeons at high volume centers; for larger, more extensive aneurysms, especially for post-dissection aneurysms; with higher rates of prior aortic surgery. After adjustment, staged repair was associated with lower odds of perioperative mortality (OR 0.5 [0.2-1.05] overall, OR 0.5 [0.3-0.9] in extensive aneurysms), but similar rates of other perioperative outcomes including TALE (thoracoabdominal life altering events-death/stroke/permanent SCI/permanent dialysis), acute kidney injury, stroke, dialysis, and SCI. Staged repairs of extensive aneurysms were similarly associated with lower adjusted long-term mortality (HR 0.5 [0.3-0.8]). There was no difference between staging methods, and no interaction between staging and whether patients had prior aortic surgeries. However, first stage TEVARs were associated with 3.3% mortality, 8.9% TALE, and 5.1% SCI, and 25% of patients did not undergo a second stage. Failure to account for complications during the first stage of staged procedures would have missed roughly 1/3 of perioperative complications including half of the deaths in the staged cohort.
CONCLUSIONS: Staged endovascular treatment of extensive aortic aneurysms was associated with lower perioperative and long-term mortality but no difference in TALE or SCI. Although staged aortic repair holds promise, more data are clearly needed to confirm these results and determine optimal methods of staging, as first stage TEVARs carry significant morbidity and failure to progress to the second stage.
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