A comparative analysis of open and endovascular repair for the ruptured descending thoracic aorta.
BACKGROUND
Successful repair of the ruptured (non-traumatic) descending thoracic aorta (rTA) remains a formidable clinical challenge. Although effective for rTA, traditional open repair (DTAR) has significant associated morbidity. With expanding indications for thoracic endovascular aortic repair (TEVAR), we describe our experience with TEVAR and DTAR in this high-risk setting to elucidate their evolving roles.


METHODS
Since the inception of our thoracic aortic endovascular program in 1993, 69 patients underwent DTAR (34) or TEVAR (35) for rTA. Patients underwent TEVAR if they were considered nonoperative candidates because of extensive comorbidities (n = 31; 88.6%) or had extremely favorable anatomy for endovascular repair (eg, mid-descending saccular aneurysm, n = 4). Aortic pathology causing rupture was fusiform aneurysm (18), saccular aneurysm/ulcer (22), and dissection (29). Associated aortobronchial fistulae (12) and aortoesophageal (1) fistulae were also present in 18.8%. Arch repair was needed in 46; total descending repair was needed in 33. Follow-up was 100% complete (mean 37.4 months).


RESULTS
Mean age was 65.9 years (DTAR 60.3 year vs TEVAR 71.3 years, P = .005). In-hospital or 30-day mortality was seen in 13 patients (TEVAR n = 4; 11.4% vs DTAR n = 9; 26.5%, P = .13). Median length of stay was shorter after TEVAR (8 days vs DTAR 15 days, P = .02). Mean Kaplan-Meier survival was similar between groups (TEVAR 67.4 months vs DTAR 65.0 months, P = .7). By multivariate analysis, independent predictors of a composite outcome of early mortality, stroke, permanent spinal cord ischemia, or need for dialysis or tracheostomy included the presentation with hemodynamic instability (P < .001) and treatment with conventional open repair (P = .02).


CONCLUSIONS
An endovascular approach for the ruptured (non-traumatic) descending thoracic aorta reduces early morbidity, mortality, and duration of hospitalization, while providing equivalent late outcomes even in an older group largely considered high risk for open repair. These data support a paradigm shift, with TEVAR emerging as the preferred therapy for all patients presenting with descending aortic rupture.
Patel
Himanshu J
HJ
Department of Surgery, University of Michigan Cardiovascular Center, Ann Arbor, Mich, USA. hjpatel@med.umich.edu
Williams
David M
DM
Upchurch
Gilbert R
GR
Dasika
Narasimham L
NL
Deeb
G Michael
GM
D000368:Aged; D000369:Aged, 80 and over; D001013:Aorta, Thoracic / Q000503:physiopathology / Q000601:surgery*; D001019:Aortic Rupture / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006439:Hemodynamics; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D007674:Kidney Diseases / Q000209:etiology / Q000628:therapy; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D006435:Renal Dialysis; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D020760:Spinal Cord Ischemia / Q000209:etiology; D020521:Stroke / Q000209:etiology; D013997:Time Factors; D014139:Tracheostomy; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality