Systematic Review of Open Versus Endovascular Repair of Thoracoabdominal Aneurysms

Research Article

Ann Surg Perioper Care. 2016; 1(2): 1010.

Systematic Review of Open Versus Endovascular Repair of Thoracoabdominal Aneurysms

Andres RD¹ and Huseynova K²*

¹Department of Surgery, West Virginia University, Morgantown, West Virginia, USA

²Division of Vascular and Endovascular Surgery, West Virginia University, Morgantown, West Virginia, USA

*Corresponding author: Khumara Huseynova, Assistant Professor, Division of Vascular and Endovascular Surgery, West Virginia University, PO Box 9238, Health Sciences Center, Morgantown, West Virginia, USA

Received: October 19, 2016; Accepted: November 14, 2016; Published: November 16, 2016

Abstract

Thoracoabdominal aneurysm (TAAA) is an aneurysmal dilatation of the descending thoracic and abdominal aorta. Given the high mortality and morbidity associated with open repair of TAAA a thoracic endovascular aortic aneurysm repair (TEVAR) has been proposed. We performed a systematic review of existing studies on open repair vs TEVAR between 2000-14 with regards to mortality and neurological complications. Eleven studies were reviewed with a total of 1,713 and 317 patients for the open and TEVAR group, respectively. Our results demonstrate (open vs TEVAR): overall 30-day mortality of 7.8% vs 7.0% and spinal cord ischemia (SCI) of 4% vs 10.4%. The TEVAR group included older and unfit patients with more comorbidities. Only one study in the open group reported a stroke rate of 3.2%. Overall stroke rate for the TEVAR group was 1%. Mortality and SCI rates were not different between two groups. While endovascular repair of TAAA has acceptable short-term outcomes, open repair is not obsolete and should be offered to younger, relatively fit patients.

Keywords: Aneurysmal Dilatation; Thoracic Endovascular Aortic Aneurysm Repair; Spinal Cord Ischemia

Introduction

Thoracoabdominal aortic aneurysm (TAAA) is a dilatation of the descending thoracic and abdominal aorta 1.5 times its normal diameter [1]. TAAA are relatively uncommon. TAAA have high mortality and morbidity compared to infrarenal abdominal aortic aneurysms (AAA). The natural history of unrepaired TAAA is progressive with 52% and 17% two- and five-year survival rates, respectively [2]. The most common cause of mortality is cardiopulmonary failure in both unrepaired and surgically corrected patients with TAAA [2]. Mortality varies between 6-48% and is higher after emergency open repair [3]. Spinal cord ischemia (SCI) and stroke rates have been reported between 3-16% and 3-7%, respectively, after open repair of TAAA [4,5]. Given high mortality and morbidity associated with TAAA repair an endovascular approach has been proposed in an attempt to counterbalance complications [6]. In the absence of Level I data comparing outcomes of these two treatment methods we sought to perform a systematic review of existing studies on open and endovascular repair of TAAA with regards to mortality and neurological complications.

Methods and Search Strategy

Extensive search of Medline and EMBASE databases published between 2000-2014 was conducted for studies reporting 30-day mortality, spinal cord ischemia and/or stroke rates in patients who underwent OR and TEVAR. A manual evaluation and extraction of references from primary papers was also performed. Studies published in different journals by the same authors that involved the same study population were carefully evaluated and only one of them was included.

The search was conducted by two independent authors. Additional articles were retrieved by carefully examining references at the end of the articles. All articles published in English between 2000-14 that reported results of endovascular and/or open repair of TAAA were included. Since all studies included patients with both atherosclerotic/degenerative and connective tissue disorder-related aneurysms, both groups were included. Emergency procedures and studies focusing exclusively on redo operations were excluded. Only studies that reported separate outcomes for elective and emergent cases were included. In such cases, patient demographics were accepted for the overall study sample, unless it was reported separately for the elective and emergent groups. If a study included ruptured TAAA, descending thoracic aortic aneurysm (DTAA) or patients with a history of TAAA repair, outcomes were recalculated whenever possible, excluding those patients. Hybrid procedures combining open debranching of renal and mesenteric vessels with endovascular endograft insertion were also excluded from this review. The date of last search was May 30, 2015.

All articles that reported the outcomes of the following research questions were reviewed independently by two authors:

Disagreements about the inclusion/exclusion of a given article were reviewed carefully based on criteria employed for this systematic review and resolved via consensus. Table 1 presents inclusion criteria for this review.