title: Cohort comparison of thoracic endovascular aortic repair with open thoracic aortic repair using modern end-organ preservation strategies.
abstract: BACKGROUND
  Pivotal trials showed that thoracic endovascular aortic repair (TEVAR) has improved outcomes compared with open surgery for treating descending thoracic aortic aneurysms. However, those trials included historical open controls in which modern end-organ preservation strategies were not routinely employed. To create a more level assessment, we compared our outcomes of elective TEVAR with modern open thoracic aortic repair (OTAR) controls.
  
  
  METHODS
  A retrospective review of thoracic aortic aneurysm patients undergoing TEVAR was compared with a contemporaneous cohort of OTAR patients. Partial bypass or hypothermic circulatory arrest was used in all OTAR patients. Cerebrospinal fluid drain placement was attempted in all patients. Preoperative characteristics, operative variables, and outcomes were recorded, and the Kaplan-Meier method was used for survival estimates.
  
  
  RESULTS
  The main outcome was mortality. Secondary outcomes included postoperative spinal cord ischemia (SCI) or stroke, and any persistent neurologic deficit 30 days following the operation. During the study period, 62 patients underwent TEVAR and 56 underwent OTAR with median follow-up of 23.7 months and 36.4 months, respectively. No difference existed between the TEVAR and OTAR with respect to overall neurologic complications (8.1% vs. 12.5%, P = 0.55) as well as any residual neurologic deficit at 30 days (0% vs. 5.4%, P = 0.10). TEVAR patients had fewer complications including pneumonia (P = 0.02), rebleeding (P = 0.02), and acute kidney injury (P = 0.001). There was no difference in 30-day mortality (1.6% vs. 8.9%, P = 0.10), 1-year mortality (12.2% vs. 14%, P = 0.80), or 5-year mortality (53.9% vs. 44%, P = 0.48) between TEVAR and OTAR, respectively.
  
  
  CONCLUSIONS
  TEVAR continues to show improved perioperative outcomes with a trend toward decreased 30-day mortality and fewer major adverse events compared with OTAR. However, with the routine use of end-organ preservation strategies during OTAR, neurologic deficits, particularly SCI, can be safely reduced to comparable levels with those of TEVAR and 1-year all-cause mortality rates are similar between the groups. These OTAR results may serve as a benchmark as TEVAR is increasingly applied for other aortic pathologies, such as chronic dissection, wherein long-term efficacy is not proven.
authors.affiliation: Division of Vascular and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Dean J
authors.initials: DJ
authors.lastname: Arnaoutakis
authors.affiliation: Division of Vascular and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD.
authors.forename: George J
authors.initials: GJ
authors.lastname: Arnaoutakis
authors.affiliation: Division of Vascular and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Abularrage
authors.affiliation: Division of Vascular and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Beaulieu
authors.affiliation: Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Ashish S
authors.initials: AS
authors.lastname: Shah
authors.affiliation: Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Duke E
authors.initials: DE
authors.lastname: Cameron
authors.affiliation: Division of Vascular and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD. Electronic address: jhblack@jhmi.edu.
authors.forename: James H
authors.initials: JH
authors.lastname: Black
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D017558:Elective Surgical Procedures; D057510:Endovascular Procedures / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality / Q000517:prevention & control*; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome