TEVAR for descending thoracic aneurysms: Impact of anatomic severity and prophylactic EndoAnchors on patient outcome
Christine Ou, Juliet Blakeslee-Carter, Chad Ammar, Sarah Ongstad, Jean Panneton
Eastern Virginia Medical School Division of Vascular Surgery, Norfolk, VA
Introduction: The procedural success and durability of TEVAR depends on suitable anatomy. An anatomic severity grading (ASG) score has been developed for primary descending thoracic aneurysms (DTA). The aim of our study is to compare the outcome of patients undergoing TEVAR for DTA between low and high ASG score groups. We then evaluated outcomes of high ASG score patients with TEVAR who were repaired without or with prophylactic EndoAnchors (EA) for primary descending thoracic aneurysms (DTA) with complex anatomy.
Methods We reviewed all patients who underwent TEVAR for primary DTA from 2008-2017. We established a cohort of patients with DTA and categorized them according to low or high ASG scores. ASG score calculations were achieved using preoperative CTA images and 3D software reconstruction. The cut off for high ASG score was 24. Patients were further divided into three groups, low ASG score, high ASG score without EA, and high ASG score with prophylactic EA. Primary endpoints included technical success, aortic related reintervention, Type 1 endoleak and late aortic related mortality. Our mean follow up was 3.5 years.
Results Of 86 patients diagnosed with DTA, there was 23 were in the low ASG group (<24) and 63 in the high ASG group (>24). We further subdivided the high ASG group into a no EA (n=43) and EA (n=20) group. Patient demographics showed no significant difference in age, diabetes, hypertension, myocardial infarction, or peripheral arterial disease. There was a significant difference between the No EA and EA group in mean ASG score (32.9 vs 38.5, p=0.001). Technical success was 100% in the low ASG, 97.6% in the high ASG group with no EA, and 100% in the high ASG group with prophylactic EA. We further analyzed the low ASG (n=23) vs the high ASG No EA and high EA groups to determine if complex anatomy influenced TEVAR outcomes. Kaplan Meier curve showed freedom from Type 1 endoleak at 1 and 3 years was 96% and 96% for low ASG, 93% and 74% for high ASG with No EA, and 100% and 100% for high ASG with EA respectively (p=0.002). Freedom from aortic related reintervention at 1 and 3 years was 100% and 100% for low ASG, 90% and 65% for high ASG with no EA, and 95% and 95% for high ASG with EA respectively (p=0.001).
Conclusion The ASG score provides a reliable quantitative assessment to predict the technical difficulty and outcome of TEVAR for DTA. Low ASG score patients have better outcomes with TEVAR repair as compared to high ASG score patients. Within high ASG score patients, EndoAnchors significantly decrease late Type 1 endoleaks and aortic related reinterventions. Utilizing prophylactic EndoAnchors in these patients with complex anatomy offers improved outcomes similar to patients with more favorable anatomy.
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