December 12, 2008

A 15 Year Comparative Analysis of Open and Endovascular Repair for the Ruptured Descending Thoracic Aorta

Himanshu J. Patel, MD, David M. Williams, MD, Gilbert R. Upchurch, MD, G. Michael Deeb, MD.
University of Michigan Hospitals, Ann Arbor, MI, USA.

OBJECTIVES:
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, 66 patients underwent DTAR (34) or TEVAR (32) for rTA. Patients underwent TEVAR if they were considered nonoperative candidates because of extensive comorbidities (n=28, 87.5%), or had extremely favorable anatomy for endovascular repair (e.g. mid-descending saccular aneurysm, n=4). Aortic pathology causing rupture was fusiform aneurysm (18), saccular aneurysm/ulcer (21) and dissection (27). Associated aortobronchial (12) and aortoesophageal fistulae (2) were also present in 21.2%. Arch repair was needed in 46; total descending repair in 33. Followup was 100% complete (mean 36.3 months)
RESULTS:
Mean age was 65.0 years (DTAR 60.3 vs. TEVAR 70.0, p=0.016). Median length of stay was shorter after TEVAR (9 days vs. DTAR 13 days, p=0.039). Early mortality was seen in 13 patients (TEVAR n=4, 12.5% vs. DTAR n=9, 26.5%, p=0.15). Early adverse events, as assessed by a composite outcome of death, stroke, paralysis or need for dialysis or tracheostomy, were less frequent after TEVAR (p=0.048). Endoleak was seen in 8 patients (25%). Mean Kaplan-Meier survival was similar between groups (TEVAR 63.2 months vs. DTAR 65.7 months, p=0.4).
CONCLUSIONS:
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.

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