Analysis Supports TEVAR for Ruptured Descending Thoracic Aorta

December 3, 2009—According to Himanshu J. Patel, MD, et al, successful repair of the ruptured (nontraumatic) descending thoracic aorta (rTA) remains a formidable clinical challenge. Although effective for rTA, traditional open repair (DTAR) has significant associated morbidity. With expanding indications for thoracic endovascular aortic repair (TEVAR), the investigators analyzed their experience with TEVAR and DTAR in this high-risk setting to elucidate the evolving roles of these procedures. The evaluation was published in the Journal of Vascular Surgery (2009;50:1265-1270).

From their experience, the investigators concluded that an endovascular approach for the rTA reduces early morbidity, mortality, and duration of hospitalization while providing equivalent late outcomes, even in an older group largely considered too high risk for open repair. These data support a paradigm shift, with TEVAR emerging as the preferred therapy for all patients presenting with descending aortic rupture.

The investigators stated that since the inception of their thoracic aortic endovascular program in 1993, 69 patients underwent DTAR (34) or TEVAR (35) for rTA. Patients underwent TEVAR if they were considered nonoperative candidates because of extensive comorbidities (n = 31; 88.6%) or had extremely favorable anatomy for endovascular repair (eg, mid-descending saccular aneurysm, n = 4). Aortic pathologies causing rupture were fusiform aneurysm (18), saccular aneurysm/ulcer (22), and dissection (29). Associated aortobronchial fistulae (12) and aortoesophageal fistulae (1) were also present in 18.8%. Arch repair was needed in 46; total descending repair was needed in 33. Follow-up was 100% complete (mean time, 37.4 months).

As the investigators reported in the Journal of Vascular Surgery, the mean age was 65.9 years (DTAR, 60.3 year vs TEVAR, 71.3 years; P = .005). In-hospital or 30-day mortality was seen in 13 patients (TEVAR [n = 4], 11.4% vs DTAR [n = 9], 26.5%; P = .13). Median length of stay was shorter after TEVAR than DTAR (8 days vs 15 days; P = .02). Mean Kaplan-Meier survival was similar between groups (TEVAR, 67.4 months vs DTAR, 65 months; P = .7). By multivariate analysis, independent predictors of a composite outcome of early mortality, stroke, permanent spinal cord ischemia, or need for dialysis or tracheostomy included the presentation with hemodynamic instability (P < .001) and treatment with conventional open repair (P = .02).