Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
J Vasc Surg. 2023 Dec;78(6):1392-1401.e1. doi: 10.1016/j.jvs.2023.06.104. Epub 2023 Aug 30.
Saccular-shaped thoracic aortic aneurysms (TAAs) are often treated at smaller diameters compared with fusiform TAAs, despite a lack of strong clinical evidence to support this practice. The aim of this study was to examine differences in presentation, treatment, and outcomes between saccular TAAs and fusiform TAAs in the descending thoracic aorta. We also examined the need for sex-specific treatment thresholds for TAAs.
All Vascular Quality Initiative (VQI) patients undergoing thoracic endovascular aneurysm repair (TEVAR) for degenerative TAAs in the descending thoracic aorta from 2012 through 2022 were reviewed. Patients were stratified by urgency: emergent/urgent vs elective repairs (ruptured/symptomatic). Demographics, comorbidities, anatomical/procedural characteristics, and outcomes for fusiform TAAs and saccular TAAs were compared. Cumulative distribution curves were used to plot the proportion of patients who underwent emergent/urgent repair according to sex-stratified aortic diameter.
Among 655 emergent/urgent TEVARs, 37% were performed for saccular TAAs, whereas among 1352 elective TEVARs, 35% had saccular TAA morphology. Compared with fusiform TAAs, saccular TAAs more frequently underwent emergent/urgent (ruptured/symptomatic) TEVAR below the repair threshold in both females (<50 mm: 38% vs 10%; relative risk, 3.39; 95% confidence interval [CI], 2.04-5.70; P < .001), and males (<55 mm: 47% vs 21%; relative risk, 2.26; 95% CI, 1.60-3.18; P < .001). Moreover, among patients with emergent/urgent fusiform TAAs, females presented at smaller diameters compared with males, whereas there was no difference in preoperative aneurysm diameter among patients with saccular TAAs. Regarding outcomes, emergent/urgent treated saccular TAAs had similar postoperative outcomes and 5-year mortality compared with fusiform TAAs. Nevertheless, in the elective cohort, patients with saccular TAAs had similar postoperative mortality compared with those with fusiform TAAs, but a lower rate of postoperative spinal cord ischemia (0.7% vs 3.2%; P = .010). Furthermore, patients with saccular TAAs had a higher rate of 5-year mortality compared with their fusiform counterparts (23% vs 17%; hazard ratio, 1.53; 95% CI, 1.12-2.10; P = .010).
Patients with saccular TAAs underwent emergent/urgent TEVAR at smaller diameters than those with fusiform TAAs, supporting current clinical practice guideline recommendations that saccular TAAs warrant treatment at smaller diameters. Furthermore, these data support a sex-specific treatment threshold for patients with fusiform TAAs, but not for those with saccular TAAs. Although there were no differences in outcomes following TEVAR between morphologies in the emergent/urgent cohort, patients with saccular TAAs who were treated electively were associated with higher 5-year mortality compared with those with fusiform TAAs.
与梭形胸主动脉瘤（TAAs）相比，囊状 TAA 通常在较小的直径时进行治疗，尽管缺乏强有力的临床证据支持这种做法。本研究的目的是研究在降主动脉中囊状 TAA 和梭形 TAA 在表现、治疗和结局方面的差异。我们还研究了是否需要针对 TAA 进行特定性别的治疗阈值。
回顾了 2012 年至 2022 年间所有接受胸主动脉腔内修复术（TEVAR）治疗降主动脉退行性 TAA 的血管质量倡议（VQI）患者。根据紧急/紧急程度对患者进行分层：紧急/紧急 vs 择期修复（破裂/有症状）。比较了梭形 TAA 和囊状 TAA 的一般资料、合并症、解剖/手术特征和结局。使用累积分布曲线绘制根据性别分层的主动脉直径，绘制接受紧急/紧急修复的患者比例。
在 655 例紧急/紧急 TEVAR 中，37%为囊状 TAA，而在 1352 例择期 TEVAR 中，35%为囊状 TAA 形态。与梭形 TAA 相比，女性中在紧急/紧急 TEVAR 阈值以下更频繁地对囊状 TAA 进行治疗（破裂/有症状：<50mm：38% vs 10%；相对风险，3.39；95%置信区间[CI]，2.04-5.70；P<.001），男性中也是如此（<55mm：47% vs 21%；相对风险，2.26；95%CI，1.60-3.18；P<.001）。此外，在紧急/紧急梭形 TAA 患者中，女性的就诊直径较小，而囊状 TAA 患者术前动脉瘤直径无差异。关于结局，紧急/紧急治疗的囊状 TAA 与梭形 TAA 相比，术后结局和 5 年死亡率相似。然而，在择期组中，囊状 TAA 患者的术后死亡率与梭形 TAA 患者相似，但脊髓缺血的发生率较低（0.7% vs 3.2%；P=.010）。此外，囊状 TAA 患者的 5 年死亡率高于梭形 TAA 患者（23% vs 17%；风险比，1.53；95%CI，1.12-2.10；P=.010）。
与梭形 TAA 相比，囊状 TAA 患者接受紧急/紧急 TEVAR 的直径较小，支持当前临床实践指南建议对囊状 TAA 进行治疗，直径较小。此外，这些数据支持对梭形 TAA 患者进行特定性别的治疗阈值，但不支持对囊状 TAA 患者进行特定性别的治疗阈值。尽管在紧急/紧急组中，两种形态的 TEVAR 后结局无差异，但接受择期治疗的囊状 TAA 患者的 5 年死亡率高于梭形 TAA 患者。
