The open repair of descending thoracic and thoracoabdominal aneurysms is associated with positive short-term outcomes and better intermediate-term outcomes than endovascular repair, according to new data published in the Annals of Thoracic Surgery.
“Endovascular repair is increasingly used in this setting, extending beyond patients at high risk from open surgery to those at moderate and low risk,” lead author Michael Tong, MD, MBA, with Cleveland Clinic’s department of thoracic and cardiovascular surgery, said in a prepared statement. “This trend is fueled by patients’ preference for the less-invasive nature of endovascular repair despite open repair being the gold standard for these aneurysms. Yet while early results with endovascular repair have been good, later outcomes have not been well described.”
The analysis included 1,053 patients treated at Cleveland Clinic between January 2000 and January 2010.
While open repair was used to treat 43.4% of those patients, endovascular repair was used to treat the rest of the cohort. The authors turned to propensity-score matching for their analysis, resulting in 278 well-matched pairs.
Comparison of the matched cohorts showed similar in-hospital outcomes when it came to mortality, spinal cord ischemia, permanent paralysis or paraplegia and stroke.
Open repair was also associated with higher rates of acute kidney failure (8.6% vs. 3.3%) and prolonged ventilation (46% vs. 6.3%), longer median ICU stays (5 vs. 3 days) and longer median postoperative hospital stays (11 vs. 6 days).
For open repair, survival was 89% at six months, 88% at one year, 74% at five years and 52% at 10 years. For endovascular repair, meanwhile, survival was 87% at six months, 82% at one year, 55% at five years and 33% at 10 years.
The authors also found that freedom from aortic reintervention was higher in the open repair group than the endovascular repair group at one year (99% vs. 96%, respectively), five years (98% vs. 88%) and 10 years (96% vs. 79%).
In addition, in the endovascular repair group, average aneurysm size dropped in the first postoperative year but then gradually rose, failing to recover to normal range.
“After the early hazard phase, we found a survival advantage with open repair compared to endovascular repair,” Tong said.
The authors explained that the reasons for the deviation in mortality over time may be linked with patient selection and device failure.
“Despite our findings, the trend toward greater endovascular repair is likely to continue,” Tong said. “So we emphasize that rigorous lifelong follow-up is imperative for patients who undergo endovascular repair, with planning for intervention in those demonstrating aneurysm sac growth. And our findings argue for open surgery in patients with poor landing zones and in young patients with low surgical risk and long life expectancy.”
Read the full study here.