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. 2023 Jul;66(1):58-66.
doi: 10.1016/j.ejvs.2023.04.013. Epub 2023 Apr 21.

Outcomes of Complex Endovascular Treatment of Post-Dissection Aneurysms

Thomas F X O'Donnell  1 , Priya B Patel  2 , Christina L Marcaccio  3 , Kirsten D Dansey  3 , Nicholas J Swerdlow  3 , Vinamr Rastogi  3 , Virendra I Patel  4 , Adam W Beck  5 , Sara L Zettervall  6 , Marc L Schermerhorn  3
Affiliations

Outcomes of Complex Endovascular Treatment of Post-Dissection Aneurysms

Thomas F X O'Donnell et al. Eur J Vasc Endovasc Surg. 2023 Jul.

Abstract

Objective: Reports of endovascular treatment of chronic post-dissection aneurysms are limited to high volumes centres, posing questions about generalisability.

Methods: All endovascular repairs of intact pararenal and thoraco-abdominal aneurysms in the Vascular Quality Initiative from 2014 to 2021 were studied, and peri-operative and long term outcomes were compared between repairs of degenerative and post-dissection aneurysms. Peri-operative outcomes were compared using mixed effects logistic regression, and long term outcomes using Medicare linkage.

Results: There were 123 patients who completed treatment for post-dissection aneurysms and 3 635 for degenerative aneurysms, with 36% of post-dissection repairs and 6.7% of degenerative repairs performed in a staged fashion (p < .001). The majority (84%) of post-dissection aneurysms were extensive thoraco-abdominal aneurysms (TAAAs: Crawford Type 1, 2, 3, 5), compared with 22% of degenerative aneurysms (p < .001). Physician modified endografts were the primary repair type for post-dissection (73%), while commercially available fenestrated grafts were the dominant repair for degenerative (48%). The first stage of staged procedures was associated with a 2.8% peri-operative mortality rate, 5.1% spinal cord ischaemia, and 8.9% thoraco-abdominal life altering events (the composite of peri-operative death, stroke, permanent spinal cord ischaemia, and dialysis). Th final stage procedure and fluoroscopy times were similar, but technical success was lower in post-dissection repairs (75% vs. 83%, p = .018), both due to issues with the main endograft or bridging vessels (11% vs. 6.6%, p = .055), and types 1and 3 endoleak at completion (17% vs. 10%, p = .035). In addition, high volume surgeons had two fold higher odds of technical success than their low volume counterparts. Adjusted peri-operative outcomes were similar between pathology types, including when comparisons were restricted to extensive TAAAs. Crude and adjusted three year survival were similar, but three year re-interventions were significantly higher following post-dissection repairs (p < .001).

Conclusion: Complex endovascular repair of chronic post-dissection aneurysms is feasible but is associated with high rates of re-interventions and non-trivial rates of lack of technical success. More data are needed to evaluate the long term durability of these procedures, and the utility of centralising these complex procedures.

Keywords: Aortic aneurysm; Endovascular repair; Fenestrated endovascular aneurysm repair; Post-dissection aneurysm; Thoraco-abdominal aneurysm.

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Conflict of interest statement

CONFLICT OF INTEREST

C.M. is supported by grant number F32HS027285 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. P.P. is supported by the Harvard-Longwood Research Training in Vascular Surgery NIH T32 Grant 5T32HL007734.

Figures

Figure 1.
Figure 1.
Flowchart of Patients Undergoing Staged Endovascular Repair of degenerative and post-dissection aneurysms in the Vascular Quality Initiative 2014–2021
Figure 2.
Figure 2.
Late Reintervention in cohort of patients undergoing complex endovascular repair of degenerative and post-dissection aneurysms in the Vascular Quality Initiative 2014–2021 with Medicare Linkage. P < .001. Dashed line on post-dissection indicates where standard errors exceed 0.1
See this image and copyright information in PMC

Comment in

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