TEVAR Affirmed as First-line Therapy for Traumatic Thoracic Aorta Injury

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In patients with acute damage to the descending thoracic aorta, endovascular repair is associated with lower short- and long-term mortality compared with traditional open repair, according to a small study published in the March 2012 issue of Archives of Surgery. The researchers say thoracic endovascular aortic repair (TEVAR) should be first-line therapy in such patients.

Mark K. Eskandari, MD, of Northwestern University Feinberg School of Medicine (Chicago, IL), and colleagues analyzed early and late outcomes in 100 patients treated at their institution from 2001 to 2010. Indications for intervention included ruptured degenerative aneurysm, blunt traumatic transection, large pseudoaneurysm, and symptomatic penetrating ulcer.

All patients underwent CT angiography to assess suitability for TEVAR. Overall, 76 patients met the requirements and underwent endovascular repair, each receiving an average of 2.2 stent grafts. The remaining 24 patients underwent open thoracic repair.

Demographics and comorbid conditions were similar between the 2 groups, with the exception of more previous aortic surgery (P = 0.02) and older age (P = 0.01) in the open repair group.

Lower Mortality with TEVAR

Compared with open repair, TEVAR resulted in lower 30-day mortality and fewer respiratory complications. Rates of postoperative MI, acute renal failure, and stroke as well as mean length of hospital stay were similar between the 2 groups (table 1).

Table 1. Postoperative Outcomes for Open vs. Endovascular Repair

 

TEVAR
(n = 76)

Open Repair
(n = 24)

P Value

Thirty-Day Mortality

8%

29%

0.007

Respiratory Complications

16%

48%

0.004

Length of Stay, days

13.5

16.3

0.30

Postop MI

5%

13%

0.35

Acute Renal Failure

12%

13%

0.88

Stroke

8%

9%

0.86


The open repair group had a higher rate of moderate to severe complications including bleeding, wound infection, sepsis, limb ischemia, intestinal ischemia, deep vein thrombosis, graft aortic occlusion, and temporary recurrent laryngeal palsy.

In the TEVAR group, 19 patients (25%) required surgical reintervention either during the initial hospitalization (n = 9) or during follow-up (n = 10). Of these, 13 required aortic reintervention. Seven patients were treated by endovascular technique with deployment of additional stent grafts, while 6 required conversion to open aortic repair.

The overall mortality rate was 67% for open repair vs. 28% for TEVAR (P = 0.001). Patients in the TEVAR group had higher 1-, 3-, and 5-year survival (P < 0.001). Independent predictors of mortality included age (P = 0.004) and open repair (P = 0.001).

According to the study authors, optimal outcomes with endovascular intervention require appropriate preoperative planning and technical expertise.

They note that challenges facing endovascular intervention include:

  • Need for 2-cm proximal and distal landing zones to achieve fixation and seal
  • Lack of disease-specific endograft designs enabling flexible delivery with durable seal and attachment
  • Access restrictions
  • Risk of stroke and spinal ischemia
  • Need for long-term surveillance

They also point out that in their experience, nearly 25% of patients require revascularization of a major trunk vessel at the time of TEVAR to facilitate the proximal seal and attenuate the risk of new neurological events, thus adding to the complexity of the procedure. With the introduction of commercially available stent grafts, however, the incidence of new neurological events has decreased, they say. But spinal ischemia remains a concern. In the current study, the complication occurred in 8% of the TEVAR group—a rate higher than has been reported in some registry-based studies.

Lack of Subgroup Analysis

In a critique accompanying the study, Christopher J. Abularrage, MD, of the Johns Hopkins Hospital (Baltimore, MD), takes issue with the lack of subgroup analysis in the study, noting that despite the fact that outcomes for traumatic transections are known to be different from those involving complicated acute type B dissection or ruptured degenerative aneurysms, “all [acute catastrophes of the descending thoracic aorta] are lumped into a single category, leading to the already well-known conclusion that TEVAR is associated with decreased mortality compared with open repair.”

Dr. Abularrage writes that while a randomized trial comparing open and endovascular treatment of these patients is unlikely to occur, a prospective study of all types of acute injuries of the descending thoracic aorta is needed to evaluate the outcomes by etiology. “Only then can evidence-based recommendations be made,” he adds.

In an email communication with TCTMD, Philip P. Goodney, MD, MS, of Dartmouth-Hitchcock Medical Center (Lebanon, NH), added that the study demonstrates many of the strengths and limitations in the literature surrounding the use of TEVAR in emergencies of the thoracic aorta.

“This represents one of the largest single-center series of emergent TEVARs, and many were complex enough to require either proximal or distal debranching procedures,” Dr. Goodney said. “This effort is admirable and their outcomes meet or exceed those of any center in the country.”

More Work Needed to Clarify When to Use TEVAR

However, he added that the study does not delineate why some patients were selected for open repair and others for TEVAR.

“Further, adjuncts such as spinal protection were used in some patients but not in others,” Dr. Goodney pointed out. “Therefore, while TEVAR seems superior to open surgery based on initial review of their work, these differences and limitations in study design limit the inferences that can be made from this study.”

Looking ahead, Dr. Goodney said this study and others like it can serve to inform larger, controlled trials of TEVAR for distinct thoracic emergencies.

“With industry and federal support, vascular surgeons can lead efforts in solidifying the evidence that ‘endovascular first’ is the best option in patients presenting with thoracic aortic emergencies,” he concluded.

 


Sources:
1. Naughton PA, Park MS, Morasch MD, et al. Emergent repair of acute thoracic aortic catastrophes: A comparative analysis. Arch Surg. 2012;147:243-249.

2. Abularrage CJ. Thoracic aortic endovascular aneurysm repair for acute thoracic aortic catastrophes: The need for subgroup analysis. Arch Surg. 2012;147:249-250.

 

 

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Disclosures
  • Dr. Eskandari reports serving as a consultant for Harvard Clinical Research.
  • Dr. Abularrage reports no relevant conflicts of interest.
  • Dr. Goodney reports receiving support from the National Heart, Lung, and Blood Institute and the Society for Vascular Surgery Foundation/American College of Surgeons.

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