Outcomes of secondary procedures after primary thoracic endovascular aortic repair

ORIGINAL ARTICLE European Journal of Cardio-Thoracic Surgery 49 (2016) 770–777 doi:10.1093/ejcts/ezv279 Advance Access publication 4 September 2015 Cite this article as: Nozdrzykowski M, Luehr M, Garbade J, Schmidt A, Leontyev S, Misfeld M et al. Outcomes of secondary procedures after primary thoracic endovascular aortic repair. Eur J Cardiothorac Surg 2016;49:770–7. Outcomes of secondary procedures after primary thoracic endovascular aortic repair† Michal Nozdrzykowskia,‡*, Maximilian Luehra,‡, Jens Garbadea, Andrej Schmidtb, Sergey Leontyeva, Martin Misfelda, Friedrich-Wilhelm Mohra and Christian D. Etza a b Department of Cardiac Surgery, Leipzig Heart Centre – University of Leipzig, Leipzig, Germany Department for Interventional Angiology, University Hospital Leipzig, Leipzig, Germany Received 18 November 2014; received in revised form 12 June 2015; accepted 30 June 2015 Abstract OBJECTIVES: The purpose of this study is to retrospectively evaluate, with an ‘all-comers’ approach, the survival and outcome of patients following secondary surgical or interventional procedures after thoracic endovascular aortic repair (TEVAR). METHODS: Between October 2002 and December 2013, 371 patients with different aortic pathologies underwent primary TEVAR at our institution. Fifty-six out of the 371 patients (15.1%, 18 females, mean age 62.3 ± 13.7 years) required secondary procedures, either interventionally (N = 31; 55.4%) or surgically (N = 25; 44.6%), due to stent graft-related complications. After TEVAR complications comprised endoleaks (N = 28; 7.5%), organ malperfusion (N = 9; 2.4%), aorto-oesophageal/-bronchial fistulae (N = 9; 2.4%), stent graft infections (N = 4; 1.1%), aneurysm progression (N = 3; 0.8%), retrograde type A aortic dissection (N = 2; 0.5%) and aortic regurgitation (N = 1; 0.3%). RESULTS: The overall in-hospital mortality rate was 10.7% (N = 5): open surgery (N = 1; 4%) versus reintervention (N = 5; 16%; P = 0.14). The cumulative survival rates after secondary procedures at 6 months, 1 year and 3 years were 80.4, 73.5 and 69.3%, respectively. Postoperative complications either for open surgery or reintervention comprised stroke (8 vs 9.6%; P = 0.82), paraplegia (4 vs 6.4%; P = 0.68), renal failure (16 vs 3.2%; P = 0.09), respiratory failure (12 vs 0%; P = 0.04), sepsis (16 vs 3.2%; P = 0.87), organ malperfusion (4 vs 3.2%; P = 0.87) and need for a tertiary procedure (8 vs 6.4%; P = 0.82). CONCLUSIONS: Stent graft complications after primary TEVAR were not infrequent and often required secondary procedures for definite treatment. Endoleaks (type Ia), organ malperfusion, stent graft infections, fistula formation and expanding aneurysm occurred predominantly during early and mid-term follow-up. Despite the high-risk nature of the complications, secondary open surgical or interventional procedures may be successfully performed with an acceptable outcome. Keywords: Thoracic endovascular repair • Aortic aneurysm • Chronic aortic dissection • Stent graft complications • Reoperation • Reintervention INTRODUCTION Thoracic endovascular aortic repair (TEVAR) has become an established alternative to open surgery for a variety of thoracic aortic diseases (i.e. aneurysm and type B dissection), particularly in patients with a high operative risk and unclear overall life expectancy, or in the acutely unstable patient to achieve rapid aortic stabilization. Growing experience with endovascular interventions and continued technological advancements have resulted in a wide spectrum of indications for TEVAR and a progressively increasing utilization of new advanced technologies for more complex aortic anatomy and pathologies, e.g. thoraco-abdominal aortic aneurysms [1, 2]. However, the more liberal use of TEVAR carries the risk of serious complications that may require secondary procedures, such as endovascular reinterventions and/or open surgical repair. Experience with secondary procedures for failed or complicated primary TEVAR is limited and the outcome after reinterventions/operations is only infrequently reported. The purpose of the current report was to retrospectively evaluate, with an ‘all-comers’ approach, the survival and the outcome of patients following secondary procedures after TEVAR. PATIENTS AND METHODS † Presented at the 28th Annual Meeting of the European Association for CardioThoracic Surgery, Milan, Italy, 11–15 October 2014. ‡ Both authors contributed equally to the study. From October 2002 to December 2013, 371 patients underwent primary TEVAR, including 126 (33.9%) patients with intentional © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. * Corresponding author. Department of Cardiac Surgery, Leipzig Heart Centre – University of Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany. Tel: +49-341-8651421; fax: +49-341-8651452; e-mail: (M. Nozdrzykowski). M. Nozdrzykowski et al. / European Journal of Cardio-Thoracic Surgery 771 All patients No. of second procedures Secondary procedure P-value Age, years (median; IQR) Female sex, n (%) Hypertension, n (%) CHD, n (%) Marfan’s syndrome, n (%) Smoking, n (%) COPD, n (%) IDDM, n (%) Obesity (BMI ≥30), n (%) Renal insufficiency, n (%) Previous neurological dysfunction, n (%) Preoperative paraplegia, n (%) Stroke, n (%) Other, n (%) Previous cardiac surgery, n (%) Aortic pathology Dissection, n (%) Aneurysm, n (%) Covered rupture, n (%) Acute rupture, n (%) Fistula, n (%) Other, n (%) Total, n (%) 69 (57–75) 108 (29.1) 299 (80.6) 74 (19.9) 3 (0.8) 95 (25.6) 61 (16.4) 58 (15.6) 99 (26.7) 103 (27.8) 45 (12.1) 4 (1.1) 31 (8.4) 9 (2.4) 88 (23.7) 69 (59–76) 90 (28.6) 249 (79.0) 59 (18.7) 3 (1.0) 79 (25.1) 49 (15.6) 48 (15.2) 81 (25.7) 89 (28.3) 39 (12.4) 4 (1.3) 27 (8.5) 7 (2.2) 72 (22.8) 64 (53–72) 18 (32.1) 50 (89.3) 15 (26.8) – 16 (28.6) 12 (21.4) 10 (17.9) 18 (32.1) 14 (25.0) 6 (10.7) – 4 (7.1) 2 (3.6) 16 (28.6) 0.10 0.58 0.07 0.16 0.46 0.58 0.27 0.61 0.31 0.61 0.46 – – – 0.35 129 (35) 113 (30) 82 (22) 20 (5.5) 4 (1) 23 (6.5) 371 (100) 106 (34) 96 (30) 70 (22) 17 (5.5) 4 (1.5) 22 (7) 315 (100) 23 (41) 17 (30) 12 (21) 3 (6) – 1 (2) 56 (100) 0.28 0.90 0.80 0.70 0.48 0.10 – IQR: interquartile range; CHD: coronary heart disease; COPD: chronic obstructive pulmonary disease; IDDM: insulin-dependent diabetes mellitus; BMI: body mass index; TEVAR: thoracic endovascular aortic repair. overstenting of the left subclavian artery (LSA), for different thoracic aortic pathologies at our institution. The respective indications for primary TEVAR as well as detailed patient baseline characteristics are summarized in Table 1. absence of an adequate aortic landing zone (minimal length 20 mm) or rapid aneurysm progression. The respective complications after primary TEVAR with regard to the performed secondary procedures are listed in Table 3. Secondary procedures after thoracic endovascular aortic repair O (...truncated)