Effects Of Thoracoabdominal Aortic Aneurysm Height Index On Mid-term Survival After Fenestrated And Branched Endovascular Aortic Repair
Jesus Porras Colon, MD, Alejandro Pizano, M.D, Carlos Timaran, John Modrall, M.D, Shirling Tsai, M.D, Melissa Kirkwood, M.D, Bala Ramanan, M.D.
UTSouthwestern, Dallas, TX, USA.
Background: Size criteria for repair of thoracoabdominal aortic aneurysms (TAAA) is not as clearly defined as for infrarenal aortic aneurysms. Previous literature has shown aortic height index (AHI) to be a predictor of ascending aortic aneurysm mortality. However, the impact on AHI on mortality after TAAA repair is unclear. This study aimed to evaluate the effect of AHI on mid-term survival after fenestrated and branched endovascular aortic repair (FB-EVAR) of TAAA. Methods: Using the society for vascular surgery vascular quality initiative (VQI) national database, patients who underwent endovascular repair for TAAA I-IV (zones, I:3/4-8; II:3/4-9; III:5-9; IV:6-9) between 2013 and 2020 were stratified by AHI (cm/m) into three groups. Group-1 (≤3.17-cm/m); Group-2 (>3.17-cm/m to ≤4.06-cm/m); Group-3 (≥4.06-cm/m). Cox proportional-hazard regression and survival model were used to estimate AHI impact on all-cause death after FB-EVAR while adjusting for potential confounders. The size cut-off for survival was determined by the ROC curve. Results: Of 1248 patients who underwent FB-EVAR for TAAA, 60% were men, and the median (interquartile range) age was 71 (63-77) years. Distribution of TAAA by type was I:15%, II: 45%, III :24%, IV :16%. In AHI groups 1, 2, and 3, the median aortic diameter was 44 (37-51), 61 (58-65), and 76 (70-86) mm (P<.001), respectively. The most common group that underwent endovascular repair was group 2. On Kaplan-Meier survival analysis (Figure), midterm overall survival progressively worsened with increasing AHI. The following variables were associated with reduced survival after Cox regression analysis; dialysis (HR, 2.56; 95% CI, 0.91-5.61; P=.039), chronic obstructed pulmonary disease (HR, 1.21; 95% CI, 1.01-1.49; P=.021), and symptomatic status (HR, 0.83; 95% CI, 0.69-0.99; P=.044). The optimal AHI for TAAA repair taking into consideration mid-term survival appears to be <3.51-cm/m (AUC, 0.62, 0.59- 0.66; P<.001). FB-EVARs were performed for TAAA ≥3.51-cm/m in 46% of patients. Conclusion: Based on our analysis, the greatest mid-term survival benefit for TAAA is achieved by performing FB-EVAR for AHI lower than 3.51-cm/m. AHI appears to be a good index for estimating mortality after TAAA repair and its utility needs to be studied further in prospectively. 
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