HOLLYWOOD, FLA. — Endovascular repair of ruptured thoracic-aortic aneurysms led to significantly better outcomes than did open surgical repair in a comparison of two nonrandomized series of patients.
Emergency endovascular repair of 52 patients with ruptured thoracic aortic aneurysms (TAAs) yielded a 71% survival rate 30 days post procedure and 50% survival after 1 year, Dr. Manish Mehta said at ISET 2009, an international symposium on endovascular therapy. The patients were treated during 2005-2007 at Albany (N.Y.) Medical Center.
By contrast, the 69 patients who underwent emergency open surgical repair of a ruptured TAA during 2004-2007 had a 30-day survival rate of 45% and a 1-year survival rate of 35%. The difference was statistically significant at both follow-up times, said Dr. Mehta, a vascular surgeon and director of endovascular services at the Institute for Vascular Health and Disease at the medical center.
Open repair was used only for emergency TAA repair at the center during 2004. Endovascular repair was first used for these patients in 2005, in 29% of all cases. As the surgical staff became comfortable doing endovascular repairs, the rate of emergency cases treated this way rose to 67% in 2006, and to 90% in 2007.
Endovascular repair of ruptured TAAs also led to significantly fewer cardiac and pulmonary complications. This method “may increase our ability to treat patients with significant comorbidities who might otherwise go untreated,” Dr. Mehta said, stressing the need for longer follow-up of these patients to assess the procedure's efficacy.
Endovascular TAA repair is the standard approach for elective treatment, but not for emergency rupture repairs. The few published reports of endovascular repair of ruptured TAAs have involved small cohorts. Problems associated with emergency TAA repair include limited training opportunities, the need for a variety of stent-graft sizes, and the complex anatomies of thoracic aorta and associated vessels that may be ill suited to endovascular stent graft placement.
Slightly more than half of the patients in the open-surgery and endovascular groups were men, with an average age of 73 years. But the endovascular patients had significantly more comorbidities: a 65% prevalence of coronary artery disease, 69% hypertension, 16% chronic renal insufficiency, and 21% chronic obstructive pulmonary disease.
Endovascular repair was associated with a 324-cc reduction in blood loss, vs. more than 2 L in the open-surgery group, as well as significant reductions in average number of blood units transfused and procedure time.
During the first 30 days after repair, the endovascularly treated patients had a significantly lower incidence of myocardial infarction, need for tracheotomy, and total neurologic complications (see table), Dr. Mehta said. The incidence of ischemic colitis or colectomy, renal failure, secondary infections, and stroke was similar in the two series.
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