Safety of elective management of synchronous aortic disease with simultaneous thoracic and aortic stent graft placement

Abstract

Background: Simultaneous treatment of multilevel aortic disease is controversial due to the theoretic increase in morbidity. This study was conducted to define the outcomes in patients treated electively with simultaneous thoracic endovascular aortic aneurysm repair (TEVAR) and abdominal aortic endovascular endografting for synchronous aortic pathology.

Methods: Patients treated with simultaneous TEVAR and endovascular aneurysm repair (T&E) at the University of Florida were identified from a prospectively maintained endovascular aortic registry and compared with those treated with TEVAR alone (TA). The study excluded patients with urgent or emergency indications, thoracoabdominal or mycotic aneurysm, and those requiring chimney stents, fenestrations, or visceral debranching procedures. Demographics, anatomic characteristics, operative details, and periprocedural morbidity were recorded. Mortality and reintervention were estimated using life-table analysis.

Results: From 2001 to 2011, 595 patients underwent TEVAR, of whom 457 had elective repair. Twenty-two (18 men, 82%) were identified who were treated electively with simultaneous T&E. Mean ± standard deviation age was 66 ± 9 years, and median follow-up was 8.8 months (range, 1-34 months). Operative indications for the procedure included dissection-related pathology in 10 (45%) and various combinations of degenerative etiologies in 12 (55%). Compared with TA, T&E patients had significantly higher blood loss (P < .0001), contrast exposure (P < .0001), fluoroscopy time (P < .0001), and operative time (P < .0001). The temporary spinal cord ischemia rate was 13.6% (n = 3) for the T&E group and 6.0% for TA (P = .15); however, the permanent spinal cord ischemia rate was 4% for both groups (P = .96). The 30-day mortality for T&E was 4.5% (n = 1) compared with 2.1% (n = 10) for TA. Temporary renal injury (defined by a 25% increase over baseline creatinine) occurred in two T&E patients (9.1%), with none requiring permanent hemodialysis; no significant difference was noted between the two groups (P = .14). One-year mortality and freedom from reintervention in the T&E patients were 81% and 91%, respectively.

Conclusions: Acceptable short-term morbidity and mortality can be achieved with T&E compared with TA, despite longer operative times, greater blood loss, and higher contrast exposure. There was a trend toward higher rates of renal and spinal cord injury, so implementation of strategies to reduce the potential of these complications or consideration of staged repair is recommended. Short-term reintervention rates are low, but longer follow-up and greater patient numbers are needed to determine procedural durability and applicability.

Fig. 1

Figure demonstrates the various combinations of aortic pathologies that were the indications for patients undergoing simultaneous thoracic endovascular aortic repair (TEVAR) and endovascular aneurysm repair (EVAR). AAA, Abdominal aortic aneurysm; PAU, penetrating aortic ulcer; TAA, thoracic aortic aneurysm; TBAD, type B aortic dissection.

Fig. 2

A, Various landing zones for thoracic endovascular aortic repair (TEVAR) are depicted, along with the different types of thoracic and aortic stent graft devices used to complete the repair. B, The total extent of aortic coverage as a function of dissection and aneurysm-related indications is shown. The error bars show the standard deviation.

Fig. 3

A, Kaplan-Meier curves show (A) survival and (B) freedom from reintervention after elective simultaneous thoracic endovascular aortic repair (TEVAR) and endovascular aneurysm repair (EVAR). **The dotted lines indicate >10% standard error mean beyond those intervals.