Experience with Thoracic Aortic Stent-Grafting at the Royal Brisbane and Women’s Hospital: Outcomes from the First Decade

Michel R Hoenig, Jason Jenkins, Nicholas Boyne, Allan Kruger, Philip J Walker

Department of Vascular Surgery, Royal Brisbane & Women’s Hospital, Herston, Queensland, Australia.
University of Queensland, School of Medicine, Discipline of Surgery, Centre for Clinical Research, Herston, Queensland, Australia.

DOI: 10.4236/wjcs.2012.23009                

Abstract

Objectives: To describe thoracic endovascular aortic repair (TEVAR) outcomes at the Royal Brisbane and Women’s Hospital between 2001-2010. Design: Prospective cohort study. Results: We successfully treated 95 of 97 patients for a 98% procedural success rate. Of the treated patients, 68 (72%) were males and mean age was 61 ± 17 years. Average follow up was 3.6 ± 2.0 years. Pathologies treated were: dissection (n = 35), aneurysmal disease (n = 32), traumatic disease (n = 19), coarctation (n = 5) and miscellaneous (n = 4). There was one peri-procedural myocardial infarction. Renal complications occurred in 7 patients (3 with doubling creatinine and 4 requiring temporary renal replacement therapy). Stroke occurred in 2 patients and paresis in 2 patients (permanent in one). Six patients died during index hospitalization and 17 deaths occurred during follow-up, 2 of which were confirmed secondary to aortic pathology. Age (HR 1.08 per year, p < 0.01) and ASA class (HR 2.2 per class, p = 0.02) were independently associated with mortality. There were 25 re-interventions in 22 patients. Eighteen of these re-interventions in 16 patients were related to the management of complications of TEVAR of which 13 were for endoleaks; eight type I, four type II, one type III. Conclusion: TEVAR can be used to treat thoracic aortic pathology but questions remain regarding long-term durability.

Keywords

Aorta; Stents; Surgery

1. Introduction

Since its introduction to treat descending thoracic aneurysmal disease and aortic ulcers in 1994 [1], thoracic endovascular aortic repair (TEVAR) is being increasingly utilized to treat the entire spectrum of thoracic aortic diseases. A recent systematic review of 2828 patients from 38 non-randomized studies comparing TEVAR to open surgery for the treatment of degenerative aneurysm, dissection, traumatic rupture, intramural hematoma or penetrating ulcers showed stent-grafting to be associated with lower short-term mortality and complications rates compared to open repair [2]. However, TEVAR case series typically have limited follow up and mortality benefits compared to traditional open repair are not sustained in the longer term [2]. In the absence of evidence from randomized trials, outcomes data is relevant to establish benchmarks and to allow indirect comparison to open repair. Herein we report the TEVAR experience at The Royal Brisbane and Women’s Hospital with an emphasis on need for reintervention and survival on late follow-up.

2. Methods

This case series describes the results from our first decade of TEVAR. This includes 97 patients seen between 2001-2010 and considered for TEVAR. Open thoracic aortic surgery was undertaken at an adjacent institution with on-site cardiac surgery services. Unfortunately, we do not have an open surgery series to serve as a comparator group. This study was approved by our Hospital Research Ethics Committee. SPSS was used for statistical analysis.

Patient Characteristics

Of the 97 patients who were considered for TEVAR at our centre, 95 were successfully treated for a 98% primary procedural success rate. The two procedural failures were related to inability to track the stent-graft secondary to iliac or aortic tortuosity. Table 1 summarizes the aortic pathologies treated in the 95 patients who underwent a successful procedure stratified to acuity of intervention; acute denotes intervention within 24 hours of presentation, subacute within 1 - 14 days and chronic after 2 weeks. Aortic dissection, aneurysmal disease and

Table 1. Overview of the aortic pathologies treated with TEVAR and acuity of intervention.

traumatic aortic disease together comprised the bulk of pathology treated; n = 89 (94%). Table 2 summarizes the characteristics of the treated patients. Males comprised the majority of the cohort (72%). Patients with traumatic aortic disease, aortic coarctation or miscellaneous aortic pathology were younger than those with aneurysmal disease or dissection (51 vs 65 p < 0.001) and were less likely to have clinically-apparent atherosclerosis (11% vs 39%, p < 0.001) or renal failure at baseline (0% vs 13%, p < 0.001).

3. Results

3.1. Procedure Details

Table 3 summarizes the procedural details of the included patients. All patients received commercially-available stentgrafts. We deployed 158 endovascular devices in 95 patients for an average of 1.7 devices per patient (range 1 - 4). Femoral access was sufficient in 94% of cases with only 2 patients requiring retroperitoneal iliac exposure and 4 requiring a conduit (3 iliac, one aortic). A zone 3 or distal landing was possible in 73 of the 95 patients (77%) with more proximal landing zones required in the remaining 22 (23%) of patients. Five patients with the stent grafting landing in zone 1 underwent adjunctive/ pre-operative left carotid revascularization. Of the 17 patients with stent graft landing zone 2, 8 received adjunctive left subclavian artery revascularization with the majority of the 9 patients not revascularized being acute presentations (7 of 9 or 78%). The average length of stay after the procedure was 15 days (range 0 to 74) with a median of 10.

Conflicts of Interest

The authors declare no conflicts of interest.

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