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Aortic Pathology Determines Midterm Outcome After Endovascular Repair of the Thoracic Aorta: Report From the Medtronic Thoracic Endovascular Registry (MOTHER) Database
Study Questions:
What types of aortic pathology predict short- and intermediate-term outcomes in patients undergoing thoracic endovascular aortic repair (TEVAR)?
Methods:
The study evaluated outcomes in 979 individuals treated with TEVAR using data from five prospective trials (Medtronic, Santa Rosa, CA) with 3- to 5-year follow-up, and from a prospective registry from a single institution with variable follow-up. Outcomes included death, stroke, acute spinal cord injury, and endograft-related need for re-intervention. Outcomes at 30 days and at intermediate-term follow-up were compared between patients with thoracic aortic aneurysm (TAA), chronic type B aortic dissection, and acute type B aortic dissection.
Results:
From the cohort of 979 patients, 670 had TAA, 114 had acute type B aortic dissection, and 195 had chronic type B aortic dissection; mean follow-up was 3.1, 2.2, and 2.4 years for these groups, respectively. There were significant differences between groups in age, gender, and comorbidities including diabetes, cardiac disease, and renal impairment (p < 0.001 for each). Adverse events were observed more frequently at 30 days following elective TEVAR for TAA versus chronic type B dissection (14% vs. 7%), including higher rates of mortality (5% vs. 3%). In patients with TAA, chronic type B dissection, and acute type B dissection, freedom from aortic death was 93%, 96%, and 85%, respectively (p < 0.001); freedom from all-cause mortality was 56%, 64%, and 42%, respectively. In patients who had not died or had not been censored at 90 days, the overall death rate per 100 patient-years at maximum follow-up was 8.0, 4.9, and 3.2 per 100 patient-years for TAA, acute type B dissection, and chronic type B dissection, respectively; corresponding aorta-related mortality was 0.6, 1.2, and 0.4 per 100 patient-years for each. Freedom from aortic re-intervention at 6 years was 84%, 46%, and 71% for TAA, acute type B dissection, and chronic type B dissection, respectively.
Conclusions:
Intermediate-term outcomes following TEVAR are markedly affected by aorta pathology. Patients with TAA have the highest rates of nonaortic death, whereas those with acute type B dissection have the highest rates of aortic death.
Perspective:
There has been growing utilization of TEVAR in the treatment of patients with aortic disease in the arch and descending thoracic aorta, although intermediate-term outcomes have been incompletely understood. As long-term outcomes following abdominal endovascular repair have been disappointing, this large study of TEVAR outcomes is important, and highlights marked differences between mortality rates, mortality timing, and the cause of mortality between patients with TAA, acute type B dissection, and chronic type B dissection. Overall mortality was high in all three groups; these findings should prompt careful assessment of which patients most benefit from this procedure.
Keywords: Blood Vessel Prosthesis Implantation, Registries, Stroke, Endovascular Procedures, Follow-Up Studies, Comorbidity, Spinal Cord Injuries, Diabetes Mellitus
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