Open Descending and Thoracoabdominal Repairs Safe in Younger Patients

Patients younger than 50 years of age had superior short- and long-term outcomes following open descending/ thoracoabdominal aortic aneurysm (D/TAAA) repairs when compared to older groups in a recent study presented at the 65^th Annual Meeting & Exhibition of the Southern Thoracic Surgical Association.

Thoracic Endovascular Aortic Repair (TEVAR) is the primary treatment option for older, high-risk patients, but the treatment has a high failure rate according to Akiko Tanaka, MD, PhD, of McGovern Medical School at UTHealth in Houston, Texas. Tanaka and her team questioned whether younger patients and patients with connective tissue disorders should undergo TEVAR.

“The purpose of this study is to provide the outcomes after descending thoracic and thoracoabdominal aortic aneurysm repair in [the] younger patient population to redefine the indications for open repairs in the modern [TEVAR] era,” said Tanaka.

Researchers conducted a single-center, retrospective analysis of D/TAAA patients between 1991 and 2017. According to the abstract, 1,896 patients were classified by age younger than 50 years (87%, n = 1,642) and older than 50 years and compared perioperative and postoperative outcomes.

Younger patients were more likely to be Marfan patients (23% vs. 1%, P < 0.001). The younger group also had significantly more chronic dissection (63% vs. 26%, P < 0.001), family history of aortic aneurysms (15% vs. 6%, P < 0.001), redo (18% vs. 12%, P = 0.012), and prior ascending aortic repair (36% vs. 17%, P < 0.001), and fewer comorbidities (hypertension, chronic lung disease, chronic kidney disease, and coronary artery disease, all P < 0.001). The groups had similar frequencies of female sex (33% vs. 38%, P = 0.207) and emergent repairs (9% vs. 9%, P = 0.797). Extent II repairs were much more common in the younger cohort (28% vs. 15%, P < 0.001), and postoperative adverse events were significantly lower (30-day mortality, 6% vs. 17%, P < 0.001; paraplegia, 2% vs. 5%, P = 0.011; acute kidney injury, 18% vs 30%, P < 0.001). Adjusted analyses identified long-term mortality risks as low glomerular filtration rate, extent II repairs, emergency, redo, coronary artery disease, smoking, and cerebrovascular disease, but found that younger age was a protective factor (hazard ratio: 0.594, P = 0.001).

According to Tanaka, younger patients had lower postoperative rates of respiratory failure (31% vs. 40%, P = 0.004), newly required dialysis (12% vs. 23%, P < 0.001), and stroke (4% vs. 6%, P = 0.156), as well as slightly shorter length of stay (12 days vs. 14 days, P = 0.177). Younger patients also had lower rates of operative mortality (7% vs. 17%) but increased rates of aortic reintervention (12% vs. 4%) and treatment failure (4% vs. 1%). Younger patients had good postoperative survival rates, Tanaka stated; 10-year survival was more than 75%, and 25-year survival was 65%. “Adding treatment failure to the survival” rates didn’t significantly change these results, she said.

Both younger and older patients were at an increased risk of disabling complications as extent of repair increased, Tanaka said, adding that open surgical repair has a low treatment failure rate but younger patients—especially those with known connective disorder—should be closely followed.

Invited discussant Bradley Leshnower, MD, of Emory University in Atlanta, noted that TEVAR is not as effective in cases involving aneurysms in chronic dissections, regardless of age.

“There has been a steady push for less invasive procedures overall in cardiac and aortic surgery,” Leshnower said, adding that open surgery still remains a viable option in some circumstances. The current study serves as a benchmark to help guide whether open or endovascular surgeries should be performed on young patients, he added.