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Trends and outcomes of thoracic endovascular aortic repair with open concomitant cervical debranching
Kirthi S Bellamkonda1, Sameh Yousef2, Naiem Nassiri3
1Yale School of Medicine, New Haven, Conn.
Insights
Thoracic endovascular aortic repair (TEVAR) with cervical bypass increases morbidity and mortality, especially with two bypasses. This highlights the risks of debranching procedures for complex aortic arch cases.
Area of Science:
- Vascular Surgery
- Cardiovascular Surgery
- Surgical Outcomes Research
Background:
- Thoracic endovascular aortic repair (TEVAR) is standard for descending thoracic aortic disease.
- Cervical debranching (carotid-subclavian or carotid-carotid bypass) enables TEVAR for complex aortic arch anatomy.
- The impact of concomitant cervical bypass on TEVAR outcomes requires examination.
Purpose of the Study:
- To evaluate the perioperative outcomes of TEVAR with and without cervical debranching procedures.
- To compare outcomes between TEVAR alone, TEVAR with one bypass, and TEVAR with two bypasses.
- To identify factors associated with mortality in patients undergoing TEVAR with debranching.
Main Methods:
- Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database (2005-2017).
- Identification of patients undergoing TEVAR, categorized by the number of cervical bypasses (none, one, or two).
- Comparison of patient characteristics and perioperative outcomes; multivariable analysis for mortality predictors.
Main Results:
- 10% of 3281 TEVAR patients underwent cervical debranching, with increasing frequency over time.
- TEVAR with debranching showed higher morbidity, longer operative times, and longer hospital stays.
- Mortality significantly increased with two bypasses (22.6%) compared to one bypass (6.8%) or none (7.5%).
- Morbidity and stroke rates escalated with more bypasses; multivariable analysis confirmed increased mortality risk with two bypasses.
Conclusions:
- TEVAR with cervical debranching is associated with worse perioperative outcomes than TEVAR alone.
- The number of bypasses directly correlates with increased morbidity, stroke risk, and mortality.
- These findings provide a crucial benchmark for evaluating emerging endovascular techniques for aortic arch pathology.
Objective:
Thoracic endovascular aortic repair (TEVAR) has become the most common surgical procedure for treatment of descending thoracic aortic pathology. Cervical debranching in the form of carotid-subclavian bypass or transposition (CSBT) and carotid-carotid bypass (CCB) has enabled the use of TEVAR for the treatment of more complex anatomy involving the arch. The present study examined the effects of concomitant cervical bypass on the perioperative outcomes of TEVAR.
Methods:
The American College of Surgeons National Surgical Quality Improvement Program files (2005-2017) were reviewed. Using the Current Procedural Terminology codes, all patients who had undergone TEVAR were identified and were divided into three groups: TEVAR, TEVAR with one bypass (CSBT or CCB), and TEVAR with two bypasses (CSBT and CCB). The patient characteristics and perioperative outcomes of the three groups were compared. Multivariable analysis was performed to determine the factors associated with mortality.
Results:
A total of 3281 patients had undergone TEVAR and 10% had also undergone one or more debranching procedure (one bypass, 9%; two bypasses, 1%). The frequency of debranching had increased from 3.4% to 10.9% (P = .01) during the study period. Significant differences were found among the three groups in age, sex, smoking history, urgency of surgery, and anesthesia technique. The patients who had undergone TEVAR with cervical debranching had had significantly greater morbidity, longer operating times, and longer hospital stays compared with those who had undergone TEVAR alone. The mortality of TEVAR with two bypasses (22.6%) was significantly greater than that of TEVAR alone (7.5%) and TEVAR with one bypass (6.8%; P < .01). The total morbidity (30.9% vs 35.1% vs 67.7%; P < .001) and stroke rate (3% vs 7.5% vs 12.9%; P < .0001) increased with the increasing number of bypasses. A subgroup analysis of patients who had undergone TEVAR with one bypass showed no significant differences in mortality between TEVAR plus CSBT (6.6%) vs TEVAR plus CCB (8.8%; P = .63). Multivariable analysis showed that TEVAR with two bypasses was associated with significantly increased mortality compared with TEVAR alone (odds ratio [OR], 4.33; 95% confidence interval [CI], 1.75-10.73) and TEVAR with one bypass (OR, 3.44; 95% CI, 1.24-9.51). Older age (OR, 1.74; 95% CI, 1.42-2.13), dependent functional status (OR, 1.48; 1.00-2.19), dialysis (OR, 2.61; 95% CI, 1.57-4.33), and emergent status (OR, 3.66; 95% CI, 2.73-4.90) were also associated with mortality.
Conclusions:
TEVAR with concomitant cervical debranching has been increasingly used to treat complex aortic pathology but is associated with significantly worse outcomes than TEVAR alone. As advanced endovascular technology to treat the aortic arch emerges, the outcomes of open surgical debranching in the present study constitute an important benchmark for comparison.
