The role of thoracic endovascular repair in elective, symptomatic and ruptured thoracic aortic diseases

OBJECTIVES: Thoracic endovascular aortic repair (TEVAR) has emerged as a safe procedure in the treatment of a wide spectrum of descending thoracic aortic pathologies, with satisfactory results both in elective and urgent settings. We investigated the results of our elective, urgent and emergency TEVAR interventions. METHODS: A single-centre retrospective analysis of all consecutive patients undergoing TEVAR from 2010 to 2016 was performed. Primary end point of the study was early mortality, whereas the secondary end points included major complications according to the urgency of the procedure. The analysis was further conducted comparing symptomatic, asymptomatic and ruptured cases. RESULTS: Two hundred and eight patients were treated with TEVAR between January 2010 and April 2016 (mean age 67 +/- 12 years, 142 men, 68.3%). Patients undergoing TEVAR as a first-stage procedure for complex thoraco-abdominal repair were excluded. The indication for treatment was a dissection in most cases (n = 92, 44.2%; acute dissection in 40 cases, 19.2%), followed by thoracic aneurysms (n = 64, 30.8%), penetrating aortic ulcers (n = 37, 17.8%), intramural haematomas (n = 8, 3.8%), traumatic ruptures (n = 3, 1.4%) and other indications (n = 4, 1.8%). One hundred and eight procedures were performed electively and 100 urgently. Forty-three patients were treated on an emergency bas for aortic rupture, 44 urgently for thoracic pain and 13 for acute ischaemic complications of aortic dissection or other indications. Ischaemic complications of dissection included 1 case of mesenteric ischaemia, 3 cases of acute renal failure, 4 cases of limb ischaemia and multiple ischaemic complications in 4 cases. Other causes of urgent TEVAR included 1 patient bleeding from a bronchial artery treated with TEVAR after several embolization attempts. In-hospital mortality was 7.7%, significantly higher in the urgent setting (14% vs 1.9%, P = 0.001). Urgent procedures were also more frequently associated with major adverse clinical events (7.4% vs 26%, P = 0.0003) and specifically with paraplegia (2.8% vs 10%, P = 0.043). Perioperative mortality was significantly higher in the ruptured group compared to the symptomatic group (25.6% vs 2.3%, P = 0.002). When the analysis was conducted to compare the symptomatic and the asymptomatic patients, no differences in terms of perioperative mortality were detected. CONCLUSIONS: TEVAR is an effective treatment strategy in thoracic aortic disease. Though emergency repair of the ruptured thoracic aorta still shows high rates of perioperative mortality and morbidity, symptomatic non-ruptured and asymptomatic patients have comparable early outcomes.