LITERATURE HIGHLIGHTS: Study Supports TEVAR for Acute Catastrophe Cases

December 3, 2009—In the Journal of Vascular Surgery, Richard P. Cambria, MD, et al published findings from a multicenter clinical trial of endovascular stent graft repair of acute catastrophes of the descending thoracic aorta (2009;50:1255–1264).

According to the investigators, thoracic endovascular aortic repair (TEVAR) is applicable to a spectrum of thoracic aortic pathologies, with half of the procedures performed worldwide for indications other than degenerative aneurysms of the descending thoracic aorta (DTA). This multicenter, prospective study queried perioperative and 1-year results of TEVAR using a commercially available thoracic endoprosthesis for treating acute complicated type B dissection (cTBD), traumatic aortic tear (TT), and ruptured degenerative aneurysm (RDA) of the DTA.

As detailed in the Journal of Vascular Surgery, this prospective, nonrandomized, literature-controlled study included 59 patients (cTBD, n = 19; RDA, n = 20; TT, n = 20). The primary endpoint was the composite of death and total paraplegia in subjects at ≤ 30 days posttreatment compared with a cohort from current literature. Secondary endpoints included adverse events related to device, procedural, and systemic complications and 1-year survival rates.

The investigators reported that all 59 patients had successful endoprosthesis deployment. Fifteen of 19 patients (79%) in the cTBD group had either rupture or malperfusion syndromes at presentation. The combined 30-day mortality/paraplegia rate was 13.6% (8/59), with seven deaths (11.9%) (cTBD, 3; RDA, 3; and TT, 1) and one case of paraplegia (TT, 1.7%).

The primary endpoint for the TEVAR cohort was significantly lower (P = .008) when compared with a composite literature control of 800 patients (combined 30-day mortality/paraplegia rate of 29.6%). Thirty-day complications of any nature occurred in 48 patients (81%); 11 (18.6%) were device related, and 43 (73%) experienced one or more systemic adverse events. Six patients (10%) required additional TEVAR implantations, and three patients (5%)—one in each pathology group—required conversion to open surgery. Seventeen patients (29%) had endoleaks of any kind or degree through 30 days (cTBD, 7; TT, 2; RDA, 8). Nine patients (15.3%) had perioperative strokes with two resultant deaths. During a mean follow-up time of 409 ± 309 days, an additional 12 patients died, one patient required open conversion (cTBD), and two patients had major device-related events. Actuarial survival at 1 year was 66% (range, 52%–77%) for the entire cohort; 79% (range, 53%–92%) for cTBD; 79% (range, 53%–92%) for TT; and 37% (range, 16%–59%) for RDA. On regression analysis, age at treatment (1.05 [range, 1.01–1.09]; P = .008) and chronic obstructive pulmonary disease (4.3 [range, 1.3–14.4]; P = .02) were predictive of death at 1 year.

This study confirmed the treatment advantages of TEVAR for thoracic aortic catastrophes when compared with the literature-based results of open repair. One-year treatment results indicate a low incidence of graft-related complications. TEVAR is the preferred initial treatment for the DTA catastrophes studied herein, the investigators concluded.