Arnaoutakis Dean J, Arnaoutakis George J, Abularrage Christopher J, Beaulieu Robert J, Shah Ashish S, Cameron Duke E, Black James H
Division of Vascular and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD.
Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD.
Ann Vasc Surg. 2015 Jul;29(5):882-90. doi: 10.1016/j.avsg.2015.01.007. Epub 2015 Mar 7.
Pivotal trials showed that thoracic endovascular aortic repair (TEVAR) has improved outcomes compared with open surgery for treating descending thoracic aortic aneurysms. However, those trials included historical open controls in which modern end-organ preservation strategies were not routinely employed. To create a more level assessment, we compared our outcomes of elective TEVAR with modern open thoracic aortic repair (OTAR) controls.
A retrospective review of thoracic aortic aneurysm patients undergoing TEVAR was compared with a contemporaneous cohort of OTAR patients. Partial bypass or hypothermic circulatory arrest was used in all OTAR patients. Cerebrospinal fluid drain placement was attempted in all patients. Preoperative characteristics, operative variables, and outcomes were recorded, and the Kaplan-Meier method was used for survival estimates.
The main outcome was mortality. Secondary outcomes included postoperative spinal cord ischemia (SCI) or stroke, and any persistent neurologic deficit 30 days following the operation. During the study period, 62 patients underwent TEVAR and 56 underwent OTAR with median follow-up of 23.7 months and 36.4 months, respectively. No difference existed between the TEVAR and OTAR with respect to overall neurologic complications (8.1% vs. 12.5%, P = 0.55) as well as any residual neurologic deficit at 30 days (0% vs. 5.4%, P = 0.10). TEVAR patients had fewer complications including pneumonia (P = 0.02), rebleeding (P = 0.02), and acute kidney injury (P = 0.001). There was no difference in 30-day mortality (1.6% vs. 8.9%, P = 0.10), 1-year mortality (12.2% vs. 14%, P = 0.80), or 5-year mortality (53.9% vs. 44%, P = 0.48) between TEVAR and OTAR, respectively.
TEVAR continues to show improved perioperative outcomes with a trend toward decreased 30-day mortality and fewer major adverse events compared with OTAR. However, with the routine use of end-organ preservation strategies during OTAR, neurologic deficits, particularly SCI, can be safely reduced to comparable levels with those of TEVAR and 1-year all-cause mortality rates are similar between the groups. These OTAR results may serve as a benchmark as TEVAR is increasingly applied for other aortic pathologies, such as chronic dissection, wherein long-term efficacy is not proven.
关键试验表明，与开放手术治疗降主动脉瘤相比，胸主动脉腔内修复术（TEVAR）改善了治疗效果。然而，这些试验纳入的历史开放手术对照组未常规采用现代的终末器官保护策略。为了进行更公平的评估，我们将择期TEVAR的结果与现代开放胸主动脉修复术（OTAR）对照组进行了比较。
对接受TEVAR的胸主动脉瘤患者进行回顾性分析，并与同期接受OTAR的患者队列进行比较。所有OTAR患者均采用部分体外循环或低温循环停止技术。所有患者均尝试放置脑脊液引流管。记录术前特征、手术变量和结果，并采用Kaplan-Meier法进行生存估计。
主要结局为死亡率。次要结局包括术后脊髓缺血（SCI）或中风，以及术后30天出现的任何持续性神经功能缺损。在研究期间，62例患者接受了TEVAR，56例接受了OTAR，中位随访时间分别为23.7个月和36.4个月。TEVAR组和OTAR组在总体神经并发症方面（8.1%对12.5%，P = 0.55）以及术后30天的任何残留神经功能缺损方面（0%对5.4%，P = 0.10）均无差异。TEVAR组患者的并发症较少，包括肺炎（P = 0.02）、再出血（P = 0.02）和急性肾损伤（P = 0.001）。TEVAR组和OTAR组在30天死亡率（1.6%对8.9%，P = 0.10）、1年死亡率（12.2%对14%，P = 0.80）或5年死亡率（53.9%对44%，P = 0.48）方面均无差异。
与OTAR相比，TEVAR在围手术期的治疗效果持续改善，30天死亡率有下降趋势，主要不良事件也较少。然而，随着OTAR期间终末器官保护策略的常规应用，神经功能缺损，尤其是SCI，可以安全地降低到与TEVAR相当的水平，且两组之间的1年全因死亡率相似。随着TEVAR越来越多地应用于其他主动脉病变，如慢性夹层，而其长期疗效尚未得到证实，这些OTAR结果可作为一个基准。
