Circulation: Endo repair for aortic aneurysms holds promise, problems

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While endovascular approaches to treat thoracic aortic aneurysms may be promising for patients, there is still room for complications including endoleak and neurological problems, according to study results published online June 14 in Circulation.

While ruptured thoracic aortic aneurysms are rare—only five incidences per 100,000—they are life threatening with a death rate that exceeds 90 percent, according to the authors.

Because thoracic endovascular aortic repair is a less invasive approach to treating ruptured descending thoracic aortic aneurysms (rDTAA), Frederik H.W. Jonker, MD, of the Yale University School of Medicine in New Haven, Conn., and colleagues set out to evaluate the outcomes of patients treated by endovascular repair to solve rDTAA.

The researchers assessed 87 patients who underwent thoracic endovascular aortic repair (TEVAR) at seven sites between January 2002 and July 2009. Patients had an average age of 69.8, a mean aneurysm diameter of 54.3 mm and 40.2 percent were hemodynamically unstable. Sixty-nine percent of patients were men.

Additionally, 21.8 percent of patients had hypovolemic shock, 36.8 percent were diagnosed with contained rupture and 41.4 percent had hemothrorax.

TEVAR procedures were performed within 24 hours in 85.1 percent of patients and vascular access through the common femoral artery took place in 89.7 percent of procedures--the distal abdominal aorta was used for access in the remainder of patients.

Results showed that 30-day mortality rates were 18.4 percent and multi-organ failure and cardiac complications were to blame in 50 percent of these cases. Four patients died after the first month of intervention from complications. In addition, 12 patients died due to other complications including stroke (two patients), MI (five patients) and sepsis after resection of a sarcoma (one patient)—four causes remain unknown.

According to the researchers, respiratory complications occurred in 18.4 percent of patients while periprocedural stroke and post-op paraplegia both occurred in 8 percent of patients.

During the study, the researchers also performed contrast angiography and a chest and abdomen CT angiography to diagnose endoleaks and endograft position. Researchers found that endoleaks occured in 18.4 percent of patients.

Additionally, the researchers found 30-day mortality to be higher in patients who were hemodynamically unstable or who had prior aortic interventions.

The trial showed that freedom from aneurysm-related death and aortic reintervention at four years occurred in 54.9 percent of patients.

“Thoracic endovascular aortic repair has changed the management of elective and emergency thoracic aortic intervention,” the authors wrote. “Endovascular repair allows quick exclusion of rDTAA without cardiovascular bypass, aortic clamping or thoracotomy.”

While overall the endovascular results seemed promising, the authors said that there may be room for neurological complications due to the fact that the emergency setting does not always fully protect the spinal cord during procedure. But, the rate of paraplegia and stroke was only 2.3 percent compared to rates of 12.5 and 25 percent in standard surgical approaches.

“Endovascular repair of rDTAA is associated with encouraging results, and a preferential endovascular approach for the management of this emergency seems appropriate,” the authors wrote.

However, they said that there is room for complications to occur. “Continued surveillance after successful endovascular management is required, and further improvement of current endovascular devices are needed to reduce the endograft-related complications and deaths during follow-up,” they concluded.