Endovascular Thoracic Aneurysm Repair Deemed Safer, Less Complications

Newswise — Endovascular, noninvasive thoracic aortic aneurysm repair (TEVAR) is safer than open aneurysm repair (OAR) as it is associated with fewer cardiac, respiratory, and hemorrhagic complications, as well as a shorter hospital stay, according to a study in the May 2009 issue of the Journal of Vascular Surgery®. Similar to trends seen across all surgical subspecialties, cardiovascular surgery has seen an explosion in endovascular therapy. Vascular disease processes including blockages, bulges, or aneurysms, tears or dissections can be treated less invasively from remote sites like the groin, using catheters, balloons and stent grafts. Usually this method results in lower death rates and fewer complications. According to Gilbert R. Upchurch, Jr., MD, from the department of surgery, section of vascular surgery at the University of Michigan Medical School in Ann Arbor, thoracic aortic aneurysms (TAAs), while rarer than abdominal aortic aneurysms (AAAs), remain a lethal disease. "The TAAs form in the chest cavity and usually go undetected unless found during tests being done for other diseases," said Dr. Upchurch. "Even in the elective setting, surgical repair of these aneurysms has a mortality rate of close to 10 percent to 20 percent. This operation also is fraught with complications, including paralysis and renal failure that also approach 20 percent."

An endograft to treat TAAs was first FDA approved in 2005. During the first three months following approval, Dr. Upchurch and fellow researchers did the first study to compare TEVAR and traditional open aneurysm repair (OAR) from a large, unselected sampling from the National Inpatient Sample (NIS database) that represents the entire scope of unruptured thoracic aortic aneurysm repairs in the United States.

"We collected and compared data of 267 patients who had TEVAR to 1,030 patients who underwent OAR," said Dr. Upchurch. "Complications, mortality, length of stay, hospital charges, patient disposition, discharge status, and patient demographics were examined."

The average ages were 66 years for OAR patients and nearly 70 years for TEVAR. Patients who had TEVAR had a higher burden of cardiovascular comorbidities, and were more likely to have hypertension, renal insufficiency, chronic obstructive pulmonary disease, cerebrovascular occlusive disease, and peripheral artery disease. In-hospital mortality was not significantly different between the two repair approaches. Researchers reported that OAR had a higher overall complication rate (33 percent versus 20 percent). The two approaches were equivalent in their rates of iatrogenic cerebrovascular accident; however, hematoma development, postoperative infections and cardiac, respiratory, and hemorrhagic complications were more likely to occur in OAR patients.

More TEVAR patients were discharged from the hospital (more likely to home rather than an extended care facility) within the first few days of their procedure, and a significant number of OAR patients were hospitalized more than 10 days.

In contrast to what occurs with the endovascular surgery in AAAs, which is uniformly believed to be more expensive than open AAA repair, the current study shows that when treating TAAs there were no significant costs or charge differences between the open and endovascular approaches. However, patients who were free of complications after TEVAR were associated with a $10,000 reduction in costs.

Dr. Upchurch pointed to the success of endovascular repair for AAAs and believes it is likely that the proportion of TAA repairs performed with an endovascular approach also will increase. He added that past research has shown that stent grafts are designed and simulation tested to be durable for 10 years and as more favorable evidence becomes available about the longevity of these grafts, more patients (particularly younger ones) will become TEVAR candidates. He noted that as technology and collective clinical experience with TEVAR increases with individual practitioners, institutional levels' volume and increased FDA graft approval, the mortality rate associated with endovascular repair for TAAs may decrease just as it has for endovascular AAA repairs.

Researchers cautioned that health care policy decisions must be based on in-hospital as well as long-term health and financial data. "Our NIS data does not report long term complications of TEVAR î º endoleak, stent migration, and stent fracture î º which are known to occur frequently after discharge," explained Dr. Upchurch. "Also, TEVAR patients currently require life-long computer tomography surveillance. Therefore further long-term studies comparing the post-operative complications, mortality, and economic impact of both approaches using different data sources is warranted.

"However, studies of mid-term follow-up for TEVAR show that the real concern for death lies in the immediate perioperative period before hospital discharge, suggesting that our mortality rate accurately captures the bulk of repair-related deaths," added Dr. Upchurch.

About Journal of Vascular Surgery®Journal of Vascular Surgery provides vascular, cardiothoracic and general surgeons with the most recent information in vascular surgery. Original, peer-reviewed articles cover clinical and experimental studies, noninvasive diagnostic techniques, processes and vascular substitutes, microvascular surgical techniques, angiography and endovascular management. Special issues publish papers presented at the annual meeting of the Journal's sponsoring society, the Society for Vascular Surgery. Visit the Journal web site at http://www.jvascsurg.org/.

About the Society for Vascular Surgery®The Society for Vascular Surgery (SVS) is a not-for-profit society that seeks to advance excellence and innovation in vascular health through education, advocacy, research and public awareness. SVS is the national advocate for 2,800 vascular surgeons dedicated to the prevention and cure of vascular disease. Visit the web site at www.VascularWeb.org.