The results from two studies presented at the Society of Interventional Radiology's 32nd Annual Scientific Meeting, in Seattle, WA, have revealed that endovascular thoracic aorta repair has much less risk of paralysis than open repair, in conjunction to lower morbidity and mortality rates.
Dr Jon Reidy, Guy's and St Thomas' Hospital, London, UK, presented the data from 190 (127 men and 63 women) patients in a prospective database from July 1997 to June 2005. All patients had diseased aortas in the thoracic area (degenerative aneurysm, dissections, ulcer and other pathology). A total of 128 patients were treated electively and 62 underwent urgent repair: 135 patients were under regional anesthesia (epidural). The stent-grafts were successfully deployed in 99.5% of the cases. The incidence of death and permanent paralysis was 1.6%. Patients had clinical and CTA follow-up at 30 days, 3-6 months, and yearly thereafter. The median follow-up was 20.4 months.
The incidence of death and permanent paralysis (which only included the interventional treatment) was 1.6%. In the trauma study, which also included a comparison to surgery, there was a 7.4% incidence of pneumonia and no incidences of death or paralysis in the interventional patients. In the surgery group, there was an 11% incidence of death, a 15.6% incidence of paralysis, and a 37.5% incidence of pneumonia.
"Repairing a thoracic aorta should primarily be done with a stent-graft. Compared to surgery, the interventional treatment has a much lower risk of paralysis, less than 2% compared to open surgery, which has approximately a 10% risk, even in the best of hands," commented Reidy.
Traumatic thoracic aortic injuries
A second study, presented by Dr J Chung, University of Alberta, Edmonton, Canada, compared the immediate and midterm outcomes of endovascular thoracic aorta repair with those of open repair in treating traumatic thoracic aortic injuries (TTAI).
The Alberta Trauma Registry and health records were used to identify all patients presenting with acute or chronic TTAI from April 1995 to August 2006. Pre-operative information, intra-operative variables, procedural data, outcomes, mechanism of injury, Injury Severity Score, and location and characterisation of injuries were documented.
A total of 102 patients were identified: 22 were dead on arrival or died during assessment; 19 patients were treated conservatively; 39 received an open repair; and 22 received an EVAR. A further ten patients presented with post TTAI, with three receiving an open repair and seven an EVAR. All surgical repairs were carried out prior to July 2003, all EVAR repairs after October 2002. Both groups were similar with respect to demographics and comorbidity.
Mean time from diagnosis to treatment in the surgical patients was 8.1 hours with perioperative mortality of 11% (four patients). Thoracic nerve injury occurred in four, post procedure pneumonia in 12, renal failure in one, paraparesis in three and paraplegia in five. No complications were seen in follow-up.
In the EVAR group mean time from diagnosis to treatment was 55.3 hours (p>0.005), all were technically successful with procedural mortality of 0%. Pneumonia occurred in two, deep vein thrombosis in two and cerebellar stroke in one. Three of the 20 patients who had coverage of the left subclavian artery developed chronic arm ischaemia. On mid-term follow-up (mean 12.2 months, range 3-42) there were no graft-failure complications or any vascular re-interventions.
The results demonstrate that EVAR of TTAI has a lower perioperative mortality and morbidity than open repair. Procedural success was 100% with no graft-related complications on mid-term follow-up and a significant difference in time from diagnosis to repair did not result in higher mortality or morbidity. "Our data strongly suggest that EVAR is not only a viable alternative to open repair, but the treatment of choice," concluded Chung.
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