Journal of Vascular Surgery
Volume 50, Issue 6 , Pages 1265-1270, December 2009

A comparative analysis of open and endovascular repair for the ruptured descending thoracic aorta

Presented at the 37th Annual Meeting of the Society for Clinical Vascular Surgery, Fort Lauderdale, Fla, March 20-22, 2009.

  • Himanshu J. Patel, MD

      Affiliations

    • Department of Surgery, University of Michigan Cardiovascular Center, Ann Arbor, Mich
    • Corresponding Author InformationReprint requests: Himanshu J. Patel, MD, Assistant Professor of Surgery, Section of Cardiac Surgery, CVC Room 5144, 1500 E. Medical Center Drive, SPC 5864, Ann Arbor, MI 48109-5864
    • ,
  • David M. Williams, MD

      Affiliations

    • Department of Radiology, University of Michigan Cardiovascular Center, Ann Arbor, Mich
    • ,
  • Gilbert R. Upchurch Jr, MD

      Affiliations

    • Department of Surgery, University of Michigan Cardiovascular Center, Ann Arbor, Mich
    • ,
  • Narasimham L. Dasika, MD

      Affiliations

    • Department of Radiology, University of Michigan Cardiovascular Center, Ann Arbor, Mich
    • ,
  • G. Michael Deeb, MD

      Affiliations

    • Department of Surgery, University of Michigan Cardiovascular Center, Ann Arbor, Mich

Received 25 March 2009; accepted 20 July 2009. published online 27 September 2009.

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).

Conclusion

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.

 

 Competition of interest: Himanshu J. Patel, MD, has been paid consulting fees by and is on the speaker's bureau of WL Gore Inc, and Medtronic Inc. David M. Williams, MD, has been paid consulting fees and is on the speaker's bureau of WL Gore Inc.

 The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest.

PII: S0741-5214(09)01564-X

doi:10.1016/j.jvs.2009.07.091

Journal of Vascular Surgery
Volume 50, Issue 6 , Pages 1265-1270, December 2009

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