Secondary Open Aortic Procedure Following Thoracic Endovascular Aortic Repair: Meta-Analytic State of the Art

Abstract

Background: Thoracic endovascular aortic repair is characterized by a substantial need for reintervention. Secondary open aortic procedure becomes necessary when further endoluminal options are exhausted. This synopsis and quantitative analysis of available evidence aims to overcome the limitations of institutional cohort reports on secondary open aortic procedure.

Methods and results: Electronic databases were searched from 1994 to the present date with a prospectively registered protocol. Pooled quantification of pre/intraoperative variables, and proportional meta-analysis with random effect model of early and midterm outcomes were performed. Subgroup analysis was conducted for patients who had early mortality. Fifteen studies were elected for final analysis, encompassing 330 patients. The following values are expressed as "pooled mean, 95% confidence interval." Type B dissection was the most common pathology at index thoracic endovascular aortic repair (51.2%, 44.4-57.9). The most frequent indication for secondary open aortic procedure was endoleak (39.7%, 34.6-45.1). More than half of patients had surgery on the descending aorta (51.2%, 45.8-56.6), and one fourth on the arch (25.2%, 20.8-30.1). Operative mortality was 10.6% (7.4-14.9). Neurological morbidity was substantial between stroke (5.1%, 2.8-9.1) and paraplegia (8.3%, 5.2-13.1). At 2-year follow-up, mortality (20.4%, 11.5-33.5) and aortic adverse event (aortic death 7.7%, 4.3-13.3, tertiary aortic open procedure 7.4%, 4.0-13.2) were not negligible.

Conclusions: In the secondary open aortic procedure population, type B dissection was both the most common pathology and the one associated with the lowest early mortality, whereas aortic infection and extra-anatomical bypass were associated with the most ominous prognosis.

Keywords: aorta; aortic arch; aortic disease; aortic dissection; aortic surgery.

Figure 1

Flowchart of literature search and selection process. SEAP indicates secondary endovascular aortic procedure; SOAP, secondary open aortic procedure; TEVAR, thoracic endovascular aortic repair.

Figure 2

Methodological quality assessment of the series selected for qualitative and quantitative analysis with Newcastle‐Ottawa scoring system.

Figure 3

Graphic overview: the upper half of the figure depicts a cone histogram distribution of the pathologic entities at index TEVAR, in patients who subsequently underwent SOAP. In‐depth graphic: the lower half of the figure depicts pie chart proportions of the subsets composing the pathologic entities of dissection, infective, and noninfective miscellanea. Miscellanea indicates every pathologic entity that is not aneurysm or dissection. PAU, Penetrating Aortic Ulcer; SOAP, secondary open aortic procedure; TEVAR, thoracic endovascular aortic repair.

Figure 4

Graphic overview: the left half of the figure depicts a cone histogram distribution of the indications for SOAP. In depth graphic: the right half of the figure represents pie chart proportions of the subsets composing the category “unstable aneurysm.” Expansion indicates further aneurysmal degeneration of segment previously stented; progression, aneurysmal degeneration of segments adjacent to previously stented segment; RTAD, retrograde type A dissection; rupture, rupture of previously stented segment; SOAP, secondary open aortic procedure.

Figure 5

The upper half of the figure depicts a pie graph distribution of the aortic segments and procedures in patients undergoing SOAP. The lower half of the figure provides a cone histogram distribution of the circulatory support required on the left, and pie graph proportions of the types of such circulatory support on the right. AAA indicates abdominal aortic aneurysm; CA, circulatory arrest; CPB, cardiopulmonary bypass; DTA, descending thoracic aneurysm; LHB, left heart bypass; SOAP, secondary open aortic procedure; TAAA, thoraco‐abdominal aortic aneurysm.

Figure 6

Operative mortality (in hospital or 30 days) in patients undergoing secondary open aortic procedure after thoracic endovascular aortic repair. Data on this variable were available for 14 studies, including 305 patients.8, 9, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30 The upper half of the figure represents the forest plot of the meta‐analyzed data. The lower half of the figure represents the funnel plot for the assessment of publication bias. CI indicates confidence interval.

Figure 7

Operative stroke (in hospital or in 30 days) in patients undergoing secondary open aortic procedure after thoracic endovascular aortic repair. Data on this variable were available from 12 studies, involving 268 patients.8, 9, 18, 22, 23, 24, 25, 26, 27, 28, 29, 30 The upper half of the figure represents the forest plot of the meta‐analyzed data. The lower half of the figure represents the funnel plot for the assessment of publication bias.

Figure 8

Operative paraplegia (in hospital or in 30 days) in patients undergoing secondary open aortic procedure after thoracic endovascular aortic repair. Data on this variable were available from 12 studies, involving 268 patients.8, 9, 18, 22, 23, 24, 25, 26, 27, 28, 29, 30 The upper half of the figure represents the forest plot of the meta‐analyzed data. The lower half of the figure represents the funnel plot for the assessment of publication bias.

Figure 9

Adverse outcomes at 2‐year follow‐up of secondary open aortic procedure after thoracic endovascular aneurysm repair. Data on overall mortality were available from 7 studies involving 174 patients,2, 5, 7, 8, 9, 10, 12 and their meta‐analytic results are depicted in the top forrest plot. Data on aortic mortality were available from 6 studies involving 158 patients,2, 5, 7, 8, 9, 12 and their meta‐analytic results are depicted in the middle forest plot. Data on tertiary aortic open procedure were available from 6 series involving 144 patients,2, 5, 7, 8, 10, 12 and its meta‐analytic results are depicted in the bottom forest plot.

Figure 10

Subanalysis of patients who had early death (ie, in hospital or 30‐day mortality) after secondary open aortic procedure (SOAP) post thoracic endovascular aortic repair (TEVAR). The subanalysis focused on TEVAR indication (left graph), SOAP indication (middle graph), and SOAP procedure (right graph). Color code: the number in the blue portion of the columns expresses the census of patients with a certain variable; the number in the orange portion of the columns expresses the census of the same patients who had early death; the percentage along the green lines expresses the ratio of the 2 previous numbers (done to dead ratio, DDR). DTA indicates descending thoracic aorta; RTAD, retrograde type A dissection; TAAA, thoraco‐abdominal aortic aneurysm.

Figure 11

The histograms in the left upper third of the figure represent the rates of early (ie, in hospital or 30‐day) mortality, stroke, and paraplegia after secondary open aortic procedure (SOAP). The histograms in the right upper third of the figure represent the rates of all‐cause death, aortic death, and tertiary open aortic procedure (TOAP) in the survivors of SOAP at 2‐year follow‐up (FU). The lower third of the figure represents the proportion of patients who are dead at 2‐year FU post‐SOAP, summing up pre‐ and postdischarge mortality.