Propensity-matched cohort validates findings of the VALOR trial.
The Evaluation of the Medtronic Vascular Talent Thoracic Stent Graft System for the Treatment of Thoracic Aortic Aneurysms (VALOR) trial findings noted superior 30-day and 1-year outcomes of the Talent thoracic endograft (Medtronic Vascular, Santa Rosa, Calif) compared with surgical repair of descending thoracic aneurysms (DTAs). Data from 195 prospective thoracic endovascular aneurysm repair (TEVAR) patients treated with the Talent device and 189 retrospective controls undergoing open surgical repair (OSR) from three centers of excellence were included in the trial after completion of TEVAR enrollment and compared. Such comparisons are biased by baseline differences among TEVAR vs OSR, however, propensity score (PS) analysis can reduce bias and validate such comparisons.
Logistic regression was used to generate a PS (range, 0-1) to identify baseline characteristics more likely in TEVAR. The PS estimated the probability that any patient would undergo TEVAR (eg, a PS of 0.99 represents a 99% chance a patient belongs to TEVAR). PSs were then generated for all patients, and TEVAR and OSR patients were divided into tertiles based on the PS to reduce up to 80% of inherent bias. Outcomes from the middle tertile (T2), patients equally likely (midrange PS) to be in TEVAR or OSR and therefore best matched, were compared using regression analysis and were also compared with the outcomes in the overall trial group.
Correlates of membership in TEVAR were smaller aneurysm (P < .001), anticoagulants (P < .01), no previous abdominal aortic aneurysm (AAA) repair (P < .01), no peripheral vascular disease (P = .001), statin use (P = .002), aspirin use (P = .002), older age (P = .028), race (P = .007), male gender (P = .02), and heart failure (P = .035). T2 included 68 TEVAR (PS, 0.58 ± 0.2) and 67 OSR patients (PS, 0.46 ± 0.2). VALOR overall reported differences in aneurysm size (56 mm TEVAR vs 69 mm open) and prior AAA repair (19% TEVAR vs 37% open), and this adjusted to no differences in T2 patients. In the well-matched T2 cohort, TEVAR patients had similar 30-day mortality (0% vs 3% OSR; P = .2) and improved 1-year aneurysm-related mortality rates (0% TEVAR vs 8% OSR; P = .05) compared with the OSR patients. This finding was in concurrence with the VALOR trial reporting similar benefit in TEVAR patients. The all-cause 1-year mortality showed a favorable trend for TEVAR in the VALOR trial; however, in T2 patients, 1-year all-cause mortality was similar in both groups of patients (17% TEVAR vs 15% OSR; P = .8). Age (P = .01), history of cerebrovascular accident (P < .05), antiarrhythmia medication (P = .04), and renal disease (P < .03) independently predicted all-cause and aneurysm-related mortality by regression analysis.
PS analysis is an important tool for elimination of bias inherent when retrospective controls are used. Its application to VALOR validates the long-term benefit in aneurysm-related mortality conferred by TEVAR in patients undergoing endovascular DTA repair.
Patel VI
，Conrad MF
，Kwolek CJ
，Ouriel K
，Fairman RM
，Cambria RP
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Preoperative Sarcopenia Portends Worse Outcomes After Descending Thoracic Aortic Aneurysm Repair.
Sarcopenia may be an indicator of frailty. We used the total psoas area index (TPAI) to identify sarcopenia and evaluated the effect of preoperative TPAI on outcomes after descending thoracic aortic aneurysm (DTAA) repair.
Patients with DTAA between 2007 and 2015 who were undergoing thoracic endovascular aortic repair (TEVAR) and open surgical repair (OSR) with available preoperative imaging were analyzed. Sarcopenia was defined as TPAI <6.5cm2/m2. An adverse event was defined as the composite endpoint of three or more multisystem complications, discharge to other than home, or death within 30 days.
A total of 282 of 386 DTAA repairs had imaging available for TPAI measurements; 71 of 282 (25%) patients underwent TEVAR, and 211 of 282 (75%) underwent OSR. Preoperative sarcopenia was similar in the two groups (OSR, 57% vs TEVAR, 48%, p = 0.188). Risk factors for sarcopenia were age >70 years, female sex, and large body surface area, whereas heritable thoracic aortic disease was a protective factor. OSR-treated patients with sarcopenia were older compared with patients without sarcopenia (p < 0.001), whereas TEVAR-treated patients had a similar age category distribution (p = 0.187). Patients with sarcopenia had significantly increased adverse events compared with patients who did not have sarcopenia in both groups (sarcopenia-TEVAR, 41% vs nonsarcopenia-TEVAR, 16%, p = 0.020; sarcopenia-OSR, 49% vs nonsarcopenia-OSR, 32%, p = 0.012). Determinants of long-term mortality were increasing age (parameter estimate [PE], 0.06, p < 0.001), TPAI as a decreasing linear function (PE, 0.36, p = 0.003), OSR (PE, 2.92, p = 0.003), and interaction between OSR and TPAI (PE, -0.34, p = 0.010). The interaction term showed that OSR increases long-term mortality risk in more sarcopenic patients.
Preoperative sarcopenia significantly correlated with postoperative adverse events and long-term mortality after DTAA repair. If anatomically feasible, TEVAR should be considered in sarcopenic patients.
Tanaka A
，Sandhu HK
，Al Rstum Z
，Afifi RO
，Miller CC 3rd
，Charlton-Ouw KM
，Codreanu ME
，Saqib NU
，Safi HJ
，Estrera AL
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Thoracic aortic remodeling with endografting after a decade of thoracic endovascular aortic repair experience.
Thoracic endovascular aortic repair (TEVAR) results have been studied in short-term time frames. This study aimed to evaluate midterm and long-term outcomes of TEVAR, emphasizing postoperative aortic remodeling and need for reintervention.
This is an institutional retrospective review of TEVAR for isolated descending thoracic aortic aneurysms. Data were collected from 2004 to 2018. Primary outcomes studied included aneurysm sac remodeling, freedom from reintervention, and all-cause mortality. Other outcomes studied include endoleak rates, neurologic complication rates, and any overall postoperative complication rates.
During the study period, 219 patients underwent TEVAR for descending thoracic aortic aneurysms. The median effect of TEVAR on sac diameter was a 0.7-cm decrease in size (interquartile range, -1.4 to 0.0 cm). During the study period, 80% (n = 147) of patients experienced aneurysm sac regression or stability. Perioperative neurologic complications occurred in 16% (n = 34) of patients. Significant predictors of sac growth were endoleak (odds ratio [OR], 65; P < .001), preoperative carotid-subclavian bypass (OR, 8; P = .003), and graft oversizing <20% (OR, 15; P = .046). Every 1-mm increase in aortic diameter at the proximal TEVAR landing zone led to an increased odds of endoleak (OR, 2; P = .049). Access complications (OR, 8) and subclavian artery coverage (OR, 6) significantly increased the odds of reintervention, whereas every percentage of graft oversizing protected against reintervention (OR, 0.005). Life-table analysis revealed an overall survival of 78% (71%-83%) at median follow-up. At 3 years, survival was 88% (80%-93%) for those with aneurysm sac stability or regression, whereas it was 70% (49%-84%) for those with aneurysm sac growth (P = .0402). Cox proportional hazards model showed that the only protective factor for mortality was percentage oversizing, with every 1% of oversizing having a hazard ratio (HR) of <.001 (P = .032). This was counterbalanced by the fact that patients with graft oversizing >30% had an increased odds of mortality with HR >10 (P = .049). Other significant factors that increased the odds of mortality included endoleak (HR, 3.6; P = .033), diabetes (HR, 4.1; P = .048), age (every 1-year increase in age; HR, 1.2; P = .002), year of surgery (every year subsequent to 2004; HR, 1.3; P = .012), and peripheral artery disease (HR, 5.2; P = .041).
The majority of patients (80%) experience sac stability or regression after TEVAR, which offers a clear survival advantage. Endoleaks are predictive of sac growth, conferring increased mortality. Rigorous surveillance is necessary to prevent future aortic events through reintervention.
Tanious A
，Boitano L
，Canha L
，Chou EL
，Wang LJ
，Latz C
，Eagleton MJ
，Conrad MF
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