Patient Selection Key to Improved Late Outcomes Among TEVAR Recipients

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Thoracic endovascular aortic repair (TEVAR) can be used to treat a variety of thoracic aortic pathologies with a minimal risk of intraoperative conversion and overall low rates of mortality and neurological complications, according to data published online June 6, 2011, ahead of print in Circulation.

The large, decade-long, single-center retrospective study was led by W. Anthony Lee, MD, of Christine E. Lynn Heart and Vascular Institute (Boca Raton, FL). Dr. Lee and colleagues examined a registry of all TEVARs performed at their institution and identified the first 400 consecutive cases. These included patients with aneurysms (49%), dissections (25%), penetrating ulcers (14%), traumatic transactions (6%), and other pathologies (6%).

In-hospital/30-day mortality was 6.5%. As expected, the mortality rate associated with elective procedures (2.6%) was lower than that associated with urgent (9.5%) or emergent (20%) procedures (P < 0.0001). In addition, certain pathology types had higher mortality rates (table 1).

Table 1. Pathology-Specific Mortality Between Elective vs. Nonelective Procedures

^a P = 0.001 for elective vs. urgent/emergent.

There were no acute surgical conversions, and adjunctive surgical procedures were performed in 24% of patients. Postoperative complications were minimal with 67% of patients reporting none. Permanent paraparesis/paraplegia occurred in 4.5% of patients and stroke in 3.0%.

Data on late outcomes indicated that median survival was 48.8 months with the probability of survival and freedom from secondary intervention declining over time (table 2).

Table 2. Late Outcomes in Patients Who Underwent TEVAR

Risk factors associated with mortality included stroke, urgent/emergent repair, age older than 80 years, general anesthesia, and dissection pathology.

Patient Selection Is Key

In their discussion of the results, Dr. Lee and colleagues point out that although the in-hospital mortality was similar among this group of unselected patients, the all-cause late mortality numbers were “quite sobering.”

“Indeed, the 48-month survival of 53% was considerably lower than what was reported in the 5-year follow-up of the TAG pivotal trial for both the endovascular (70%) and open (65%) treatments arms of the study and that of patients undergoing repair of abdominal aortic aneurysms (5-year survival, 66%),” they write.

However, the low 48-month survival could be due to the wide range of pathologies present among the patients studied and a higher acuity of the procedures, they note.

In fact, Dr. Lee and colleagues say the data suggest that patients who undergo TEVAR for thoracic aortic disease likely represent a subset whose comorbidities may be a greater threat than the actual disease.

“That is why patient selection is key for good outcome in this therapy,” Dr. Lee told TCTMD in a telephone interview. “The patients who have this subset of cardiovascular disease are very sick and the mere fact that one can technically perform the procedure does not always mean that such a procedure should be done, especially in the context of the economics of these types of repairs where the medical devices being used are very expensive.

“If you get these expensive procedures but a patient doesn’t have longevity, then one begins to question whether the therapy does represent a futility of care,” he added.

Study Details

The mean age of patients was 65 years. Overall, 16% of TEVAR procedures were performed emergently for ruptures; 16% urgently for symptomatic pathologies. Median duration of follow-up was 299 days.

Source:

1. Lee WA, Daniels MJ, Beaver TM, et al. Late outcomes of a single-center experience of 400 consecutive thoracic endovascular aortic repairs. Circulation. 2011;Epub ahead of print.

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