Long-Term Survival After Open Repair and Thoracic Endovascular Aortic Repair for Descending Thoracic Aortic Aneurysms
2011; Lippincott Williams & Wilkins; Volume: 124; Issue: 24 Linguagem: Inglês
10.1161/circulationaha.111.069641
ISSN1524-4539
Autores Tópico(s)Infectious Aortic and Vascular Conditions
ResumoHomeCirculationVol. 124, No. 24Long-Term Survival After Open Repair and Thoracic Endovascular Aortic Repair for Descending Thoracic Aortic Aneurysms Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBLong-Term Survival After Open Repair and Thoracic Endovascular Aortic Repair for Descending Thoracic Aortic Aneurysms Virendra I. Patel Virendra I. PatelVirendra I. Patel From the Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA. Originally published13 Dec 2011https://doi.org/10.1161/CIRCULATIONAHA.111.069641Circulation. 2011;124:2645–2646Thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysms (DTAs) was first reported by Dake et al1 in 1994. The advent of TEVAR was clinically relevant because open DTA repair had long been associated with operative mortality rates ranging from ≈5% to 7% at centers of excellence2,3 to as high as 20% to 22% in real-world practice.4,5 The favorable results6 of TEVAR with nearly 75% reduction in operative mortality in early industry-sponsored device trials led to US Food and Drug Administration approval for first commercial use in 2005 and subsequent device approvals in 2008.7,8 The operative mortality and morbidity benefits of TEVAR highlighted by numerous single-center reports,9–11 device registries,12,13 and device trials6–8 have led to widespread public and surgeon acceptance of this less invasive modality for the management of DTA in contemporary practice. As such, TEVAR has supplanted open surgical repair in the majority of patients with DTA.14,15Article see p 2661In the current issue of Circulation, Goodney et al16 reviewed the long-term survival of patients treated for DTA by the use of Medicare data from 1998 to 2007. They report that the postoperative mortality benefit afforded to patients undergoing TEVAR for intact DTA is lost within 2 years, thereby resulting in reduced long-term survival for patients treated with TEVAR (72% open versus 62% TEVAR; P=0.001). These investigators concede that the reduced long-term survival likely results from the selection of higher-risk patients for TEVAR. In support of this finding, patients treated with TEVAR were older and more likely to have comorbidities such as diabetes mellitus, myocardial infarction, chronic obstructive pulmonary disease, and chronic renal failure, all of which increase mortality risk. To correct for baseline clinical and demographic differences in patients treated with TEVAR and open DTA repair, these investigators carefully evaluated long-term survival in risk-adjusted and propensity-matched cohorts. In both analyses, the long-term survival advantage afforded patients treated with open surgery persisted. This suggests that, in the lowest-risk patients, open surgery should be the primary treatment modality, because such patients have similar operative mortality for both procedures, and carefully selected patients treated with open repair can have outstanding long-term survival (≈90%). Interestingly, they also noted a significant decrease in operative mortality and a modest 3-year survival benefit in patients treated with open repair in the years after US Food and Drug Administration approval of thoracic aortic stent grafts in comparison with those treated with open repair in the years before approval. Implicit in these findings is that higher-risk open patients were referred for TEVAR, which resulted in improved outcomes of open repair after widespread commercial availability of stent graft technology. Indeed, we documented this very finding in an analysis of practice patterns and patient outcomes following DTA repair by the use of a more limited cohort (2004–2007) of Medicare patients.14 We reported an increase in the number of DTA repairs within 2 years after stent graft availability and a shift in practice from predominantly open repair of intact DTA in 2004 (75% open/25% TEVAR; n=1400) to a majority of patients being treated with TEVAR (40% open/60% TEVAR; n=2032) by 2007. This paradigm shift was also seen in patients with ruptured DTA, traumatic thoracic aortic injury, and aortic dissection; all are diagnoses for which TEVAR currently represents off-label use.Several limitations of the Medicare data set need to be taken into consideration in light of these findings. Included data are unaudited and are based on hospital discharge and procedural billing claims. Diagnoses or comorbidities not likely to positively impact reimbursement may therefore not be included in the claims related to the index admission. The absence of such data decreases the ability to risk stratify patients or propensity match patients appropriately. In the article by Goodney and coworkers, this limitation was circumvented by only including patients with at least 1 year of Medicare eligibility to increase the capture of comorbidities. Despite this effort, the prevalence of comorbidities reported in their study are less than previously reported, suggesting at least some degree of selection bias.6–13 These investigators have rightly noted that other relevant information regarding clinical presentation, urgency of operation, aneurysm anatomy, and procedural technical details that may have early and late clinical implications are not available in the data set. Long-term follow-up data with respect to reinterventions, additional aneurysm-related procedures, and cause of death are also unavailable.Despite limitations inherent to existing administrative datasets, the use of the Medicare data in this study has several advantages. The large number of patients included ensures an adequately powered study, and available survival data are highly reproducible and reliable. Furthermore, the contemporary experience (1998–2007) representing outcomes on a national scale and across many demographic variables makes the findings of this study generalizable to most patients undergoing DTA repair in the United States today. Given the excellent long-term survival afforded low-risk patients undergoing open DTA repair, such patients should be referred to centers with the best perioperative outcomes for management. TEVAR is increasingly applied to treat patients with DTA on a national scale, and is increasingly applied in the management of higher-risk patients not likely to have been candidates for open repair in the past. Despite the use in higher-risk patients, these investigators report a 5-year all-cause mortality of 38%, which is comparable to that of patients undergoing abdominal aortic aneurysm repair in contemporary practice.17,18 In the setting of expanding use, these investigators have aptly pointed out that further analysis to define a truly high-risk cohort of patients for which no treatment is beneficial is important and necessary for the management DTA. Perhaps we can look to regional19 or national quality initiatives,20 now in their infancy, to answer such questions in the near future.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to Virendra I. Patel, MD, Massachusetts General Hospital, 15 Parkman Street, Wang ACC 440, Boston, MA 02114. E-mail vpatel4@partners.orgReferences1. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med. 1994; 331:1729–1734.CrossrefMedlineGoogle Scholar2. Estrera AL, Rubenstein FS, Miller CC, Huynh T, Letsou GV, Safi HJ. Descending thoracic aortic aneurysm: surgical approach and treatment using the adjuncts cerebrospinal fluid drainage and distal aortic perfusion. Ann Thorac Surg. 2001; 72:481–486.CrossrefMedlineGoogle Scholar3. Coselli JS, LeMaire SA, Conklin LD, Adams GJ. Left heart bypass during descending thoracic aneurysm repair does not reduce the incidence of paraplegia. Ann Thorac Surg. 2004; 77:1298–1303.CrossrefMedlineGoogle Scholar4. Cowan JA, Dimick JB, Henke PK, Huber TS, Stanley JC, Upchurch GR. 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National trends and regional variation of open and endovascular repair of thoracic and thoracoabdominal aneurysms in contemporary practice. J Vasc Surg. 2011; 53:1499–1505.CrossrefMedlineGoogle Scholar15. Conrad MF, Ergul EA, Patel VI, Paruchuri V, Kwolek CJ, Cambria RP. Management of diseases of the descending thoracic aorta in the endovascular era: a Medicare population study. Ann Surg. 2010; 252:603–610.CrossrefMedlineGoogle Scholar16. Goodney PP, Travis L, Lucas L, Fillinger MF, Goodman DC, Cronenwett JL, Stone DH. Survival after open versus endovascular thoracic aortic aneurysm repair in an observational study of the Medicare population. Circulation. 2011; 124:2661–2669.LinkGoogle Scholar17. United Kingdom EVAR Trial Investigators, Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, Sculpher MJ. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010; 362:1863–1871.CrossrefMedlineGoogle Scholar18. De Bruin JL, Baas AF, Buth J, Prinssen M, Verhoeven EL, Cuypers PW, van Sambeek Marc , Balm R, Grobbee DE, Blankenstein JD, for the Dream Study Group. Long term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med. 2010; 362:1881–1889.CrossrefMedlineGoogle Scholar19. Vascular Surgery Study Group of New England. http://www.VSGNE.org. Accessed October 22, 2011.Google Scholar20. Society for Vascular Surgery. Vascular Quality Initiative. www.vascularweb.org/practiceresources/vascular-quality-initiative. Accessed October 22, 2011.Google Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited By Acosta Santamaría V, Daniel G, Perrin D, Albertini J, Rosset E and Avril S (2018) Model reduction methodology for computational simulations of endovascular repair, Computer Methods in Biomechanics and Biomedical Engineering, 10.1080/10255842.2018.1427740, 21:2, (139-148), Online publication date: 25-Jan-2018. Azarbal A, Clavijo L and Gaglia M (2014) Antiplatelet Therapy for Peripheral Arterial Disease and Critical Limb Ischemia, Journal of Cardiovascular Pharmacology and Therapeutics, 10.1177/1074248414545126, 20:2, (144-156), Online publication date: 1-Mar-2015. Hughes K, Guerrier J, Obirieze A, Ngwang D, Rose D, Tran D, Cornwell E, Obisesan T and Preventza O (2014) Open Versus Endovascular Repair of Thoracic Aortic Aneurysms, Vascular and Endovascular Surgery, 10.1177/1538574414540484, 48:5-6, (383-387), Online publication date: 1-Jul-2014. Bansilal S, Bonaca M and Sabatine M (2014) Ticagrelor for acute coronary syndromes, Expert Review of Cardiovascular Therapy, 10.1586/14779072.2013.839205, 11:11, (1473-1484), Online publication date: 1-Nov-2013. Auricchio F, Conti M, Marconi S, Reali A, Tolenaar J and Trimarchi S (2013) Patient-specific aortic endografting simulation: From diagnosis to prediction, Computers in Biology and Medicine, 10.1016/j.compbiomed.2013.01.006, 43:4, (386-394), Online publication date: 1-May-2013. December 13, 2011Vol 124, Issue 24 Advertisement Article InformationMetrics © 2011 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.111.069641PMID: 22155993 Originally publishedDecember 13, 2011 Keywordsepidemiologyperipheral vascular diseaseendovascular graftendovascular surgeryEditorialaortic surgeryPDF download Advertisement SubjectsCardiovascular SurgeryEpidemiologyEthics and Policy
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