Thoracoabdominal aortic aneurysm life-threatening events following endovascular aortic repair
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Abstract
OBJECTIVE: This study aimed to evaluate the perioperative morbidity and mortality related to endovascular abdominal aortic aneurysm repair (EVAR), complex EVAR, and thoracic endovascular aortic repair (TEVAR), as well as the details of these procedures in order to mitigate the risks in the future. We characterized the odds of adverse outcomes and complications including death from the Society for Vascular Surgery’s Vascular Quality Initiative (VQI) registry.
METHODS: We performed a retrospective cohort study of patients who underwent infrarenal EVAR, complex EVAR, or TEVAR using data from the VQI registry between January 2011 and September 2021. Patients with missing data on landing zone were excluded, as were emergent cases. We collected data on baseline demographics, smoking status, race/ethnicity, comorbid conditions, such as body mass index (BMI), renal function, and cardiac disease. We also collected data on the procedural details, including adjuvant access. The primary outcome was post-operative thoracoabdominal aneurysm life-altering events (TALE). TALE was defined as a composite endpoint of postoperative death, permanent postoperative dialysis, permanent postoperative paralysis, and/or postoperative stroke. Secondary outcomes included identifying anatomic and procedural characteristics associated with post-operative TALE.
RESULTS: We identified all patients who underwent infrarenal EVAR (N=62143), complex EVAR (N=3665), and TEVAR (N=8981) in the VQI from January 2011 to September 2021. Patients who underwent repair following rupture or who had missing landing zone data were excluded. Thus, the final cohorts for each type of repair were: EVAR, N=58327; complex EVAR, N=3537; TEVAR, N=8335. Rates of TALE were 1.4% among EVAR patients, 4.6% among complex EVAR patients, and 10% among TEVAR patients. The rates of perioperative mortality were 1.1% in EVAR patients, 4.5% in complex EVAR patients, and 5.6% in TEVAR patients. Stroke occurred in 0.2% of EVAR patients, 1.3% of complex EVAR patients, and in 3.8% of TEVAR patients. Both transient and permanent dialysis were observed in 0.20% of EVAR patients. Dialysis was observed transiently in 1.2% of complex EVAR patients and permanently in 1.1% of complex EVAR patients. Transient dialysis was observed in 1.5% of TEVAR patients and permanently in 1.1% of TEVAR patients. Discharge to a skilled nursing facility (SNF) was observed in 5.8% of EVAR patients, 14% of complex EVAR patients, and 18% of TEVAR patients.
After adjusted analysis, symptomatic repair in EVAR patients was associated with higher odds of TALE (OR 3.4; 95% CI [2.7-4.1]), as were certain comorbidities such as chronic kidney disease (CKD) (OR 2.1; 95% CI [1.7-2.5]) and cerebrovascular disease (CVD) (OR 2.1; 95% CI [1.5-2.9]). Female sex was associated with higher odds of TALE in EVAR patients (OR 1.5; 95% CI [1.3-1.9]). Larger aneurysm diameter was also associated with higher odds of TALE in the EVAR group, particularly diameter >65 mm as compared with <55 mm (OR 2.0; 95% CI [1.6-2.5]).
For complex EVAR patients, female sex was associated with higher odds of TALE (OR 2.1; 95% CI [1.5-2.8]) as were certain comorbidities, such as CKD (OR 1.8; 95% CI [1.3-2.4]). When compared with no adjuvant access, the use of left upper extremity adjuvant access was associated with higher odds of TALE in complex EVAR patients (OR 1.6; 95% CI [1.1-2.4]). Similar to EVAR, larger aneurysm diameter trended towards an association with higher odds of TALE for complex EVAR (OR 1.5; 95% CI [0.95-2.3]). When compared with landing zone 9, more proximal landing zones were associated with higher odds of TALE: zones 3-5 (OR 2.4; 95% CI [1.2-4.4]), zones 0-2 (OR 3.5; 95% CI [1.1-11]).
When compared with proximal landing zone 3-5 in TEVAR patients, proximal landing zone 0-2 was associated with higher odds of TALE (OR 1.8; CI 95% [1.5-2.1]). When compared with no adjuvant access, the use of right upper extremity adjuvant access during TEVAR trended towards an association with higher odds of TALE (OR 1.2; CI 95% [0.80-1.8]) as did the use of left upper extremity adjuvant access (OR 1.1; 95% [0.83-1.3]). Additionally, when compared with no adjuvant access the use of multiple adjuvant access sites was associated with higher odds of TALE for TEVAR patients (OR 2.0; CI 95% [1.2-3.3]).
CONCLUSION: TALE was observed in 10% of TEVAR, 6.8% of complex EVAR, and 1.4% of EVAR patients. Factors that were commonly associated with TALE include symptomatic repair, more proximal landing zone, use of adjuvant access for complex EVAR and TEVAR, and wider aortic diameter. While TALE was observed after all three types of repair, higher rates were observed in patients who underwent complex EVAR and TEVAR.