Endovascular Repair of Thoracoabdominal Aneurysms: The Impact of Extent on Mortality
Ryan T Heslin1, John C. Axley2, Zdenek Novak2, Danielle C Sutzko2, Benjamin J Pearce2, Graeme E McFarland2, Adam W Beck2
1University of South Alabama College of Medicine, Mobile, AL;2University of Alabama at Birmingham, Birmingham, AL
INTRODUCTION: Surgical treatment of thoracoabdominal aneurysms (TAAA) historically carries 30-day mortality rates from 6% to 20%, depending on Crawford extent of disease. High mortality has driven development of less invasive endovascular therapies. Our intent is to evaluate the impact of disease extent on survival, and to determine which pre- and postoperative factors impact mortality.
METHODS: A retrospective cohort of patients treated for TAAAs was derived from the Society for Vascular Surgery Vascular Quality Initiative (SVS VQI) registry. Patients treated for asymptomatic aneurysmal disease with endovascular repair between 2011-18 were included. Extent of disease was defined by the deployment zones documented for the most proximal and distal devices entered into the VQI registry. In addition to Crawford extents I-V, patients with TEVAR without extension into the visceral aorta were categorized as Extent 0. Multivariable logistic regression models were created to identify predictors of mortality and KM plots were used to estimate survival.
RESULTS: We identified 2,053 patients who met inclusion criteria: 1,223 Extent 0, 80 Extent I, 97 Extent II, 129 Extent III, 453 Extent IV and 71 Extent V. After initial analysis, patients with similar outcomes were grouped as follows based on similar outcomes: Extent 0, Extent I-III and Extent IV-V. KM survival analysis revealed Extent I-III TAAA had poorer overall survival rates than patients with extent 0 and extent IV-V (log rank <0.001). Cox regression showed that those with COPD (OR 1.7; 95% CI, 1.31-2.24; p <0.001), postop stroke (OR 1.85; 95% CI, 1.12-3.05; p <0.05), postop respiratory complication (OR 1.70; 95% CI, 1.15-2.5; p <0.01), preop renal insufficiency (OR 1.50; 95% CI, 1.14-1.98; p <0.01), distal endoleak at completion (OR 3.38; 95% CI, 1.55-7.36; p <0.005), any postop complications (OR 2.18; 95% CI, 1.54-3.07; p <0.001), visceral inclusion (OR 2.66; 95% CI, 1.51-4.71; p <0.001), and arch & visceral inclusion (OR 2.91; 95% CI, 1.51-5.64; p <0.005) were associated with increased mortality.
CONCLUSIONS: Similar to open TAAA repair, patients with more extensive aortic disease treated with endovascular approaches have poorer survival. Given the elective nature of many of these repairs and the associated postop mortality, surgeons should use these data to inform patient discussions with regard to aneurysm size and rupture risk. 
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