title: Open surgery versus endovascular repair of ruptured thoracic aortic aneurysms.
abstract: BACKGROUND
  Ruptured descending thoracic aortic aneurysm (rDTAA) is a cardiovascular catastrophe, associated with high morbidity and mortality, which can be managed either by open surgery or thoracic endovascular aortic repair (TEVAR). The purpose of this study is to retrospectively compare the mortality, stroke, and paraplegia rates after open surgery and TEVAR for the management of rDTAA.
  
  
  METHODS
  Patients with rDTAA treated with TEVAR or open surgery between 1995 and 2010 at seven institutions were identified and included for analysis. The outcomes between both treatment groups were compared; the primary end point of the study was a composite end point of death, permanent paraplegia, and/or stroke within 30 days after the intervention. Multivariate logistic regression analysis was used to identify risk factors for the primary end point.
  
  
  RESULTS
  A total of 161 patients with rDTAA were included, of which 92 were treated with TEVAR and 69 with open surgery. The composite outcome of death, stroke, or permanent paraplegia occurred in 36.2% of the open repair group, compared with 21.7% of the TEVAR group (odds ratio [OR], 0.49; 95% confidence interval [CI], .24-.97; P = .044). The 30-day mortality was 24.6% after open surgery compared with 17.4% after TEVAR (OR, 0.64; 95% CI, .30-1.39; P = .260). Risk factors for the composite end point of death, permanent paraplegia, and/or stroke in multivariate analysis were increasing age (OR, 1.04; 95% CI, 1.01-1.08; P = .036) and hypovolemic shock (OR, 2.47; 95% CI, 1.09-5.60; P = .030), while TEVAR was associated with a significantly lower risk of the composite end point (OR, 0.44; 95% CI, .20-.95; P = .039). The aneurysm-related survival of patients treated with open repair was 64.3% at 4 years, compared with 75.2% for patients treated with TEVAR (P = .191).
  
  
  CONCLUSIONS
  Endovascular repair of rDTAA is associated with a lower risk of a composite of death, stroke, and paraplegia, compared with traditional open surgery. In rDTAA patients, endovascular management appears the preferred treatment when this method is feasible.
authors.affiliation: Section of Vascular Surgery and Interventional Radiology, Yale University School of Medicine, New Haven, CT 06510, USA.
authors.forename: Frederik H W
authors.initials: FH
authors.lastname: Jonker
authors.forename: Hence J M
authors.initials: HJ
authors.lastname: Verhagen
authors.forename: Peter H
authors.initials: PH
authors.lastname: Lin
authors.forename: Robin H
authors.initials: RH
authors.lastname: Heijmen
authors.forename: Santi
authors.initials: S
authors.lastname: Trimarchi
authors.forename: W Anthony
authors.initials: WA
authors.lastname: Lee
authors.forename: Frans L
authors.initials: FL
authors.lastname: Moll
authors.forename: Husam
authors.initials: H
authors.lastname: Atamneh
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Rampoldi
authors.forename: Bart E
authors.initials: BE
authors.lastname: Muhs
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017545:Aortic Aneurysm, Thoracic / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D016009:Chi-Square Distribution; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005060:Europe; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010264:Paraplegia / Q000209:etiology; D018579:Patient Selection; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000209:etiology; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States