Mid-term Outcomes of Single Center Experience of 400 Consecutive TEVAR

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is a minimally-invasive alternative to open repair of many thoracic aortic pathologies. To date, most of the published data involve relatively limited number of subjects and follow-up. In this descriptive study, we report our mid-term outcomes of a large, decade-long single-center TEVAR experience.
METHODS: A prospectively maintained TEVAR registry and electronic medical records at a tertiary care center were retrospectively analyzed for patient characteristics, intraoperative details, and early and late postoperative outcomes.
RESULTS: 400 consecutive TEVAR were performed from 2000-2009 using 7 endograft systems (TAG 65%, TX2 18%, Talent 6%, aortic cuff 3%, investigational 8%). Over 91% cases were performed in the last 5 years of the study. The distribution of pathologies treated included aneurysms (198, 50%), dissections (100, 25%), penetrating ulcers (54, 13%), traumatic transections (25, 6%), and other pathologies (23, 6%). Dissections represented the single fastest growing segment being treated. 69% were men, the mean age was 65±16, and 18% had prior abdominal aortic replacements. 32% of cases were performed urgently or emergently. 69% were ASA class IV and 61% underwent general anesthesia. Spinal drains were prophylactically placed in (127, 32%) cases of planned extended aortic coverage. There were no acute surgical conversions. Mean number of devices was 2.3±1.1, and 63% of cases were completed with 1 or 2 devices. Mean fluoroscopy was 24±15 min, contrast 139±54 ml, blood loss 309±316 ml, and procedure time 116±5 min. 16% required iliac conduits. 51% of proximal landing zones involved zones 0-2. Preoperative adjunctive surgical procedures were performed on 94 (24%) patients. These included arch debranching (22, 6%), 1st stage elephant trunk (20, 5%), visceral debranching (21, 5%), and left subclavian revascularization (31, 8%). Subclavian revascularizations were selectively performed in only 17% of zone 2 deployments. The median length of stay was 5 (range 1-79) days. Incidence of type I/III endoleak was 10% and 5% at 1 and 12 months, respectively. Overall 30-day mortality was 6.5% (elective 2.6%, urgent 9.5%, emergent 20%). Permanent spinal cord ischemia occurred in 3.6% and stroke in 2.1%. Kaplan-Meier estimates of survival were 81%, 76%, 69%, and freedom from secondary intervention 90%, 86%, 82% at 6, 12, and 24 months, respectively.
CONCLUSIONS: Since commercial availability of thoracic endografts, TEVAR has been used to treat a variety of thoracic aortic pathologies, many of which were off-label. With careful planning and technique, the procedures can be performed with virtually zero risk of intraoperative conversion. While overall rates of mortality and neurologic complications were relatively low, they were significantly increased in emergent repairs. There appears to be substantial number of late deaths which may represent a combination of poor patient selection or treatment failures.