Perioperative mortality, paraplegia, stroke and long-term stent related complications after TEVAR for traumatic thoracic aortic lesions

Transcription

1 Perioperative mortality, paraplegia, stroke and long-term stent related complications after TEVAR for traumatic thoracic aortic lesions Clark Zeebregts Professor of Vascular Surgery University Medical Center Groningen Department of Surgery Division of Vascular Surgery Groningen, The Netherlands Munich, Germany December 8, 2017

2 Disclosure Consultant for Vascutek Received research grants from W.L. Gore & Associates, LeMaitre Vascular, Atrium Maquet Getinge Group, and Cook Medical

3 Traumatic thoracic aortic lesions High-energy blunt thoracic trauma may lead to traumatic thoracic aortic lesions (TTAL) in 1-2% of patients. 80% of victims with blunt aortic injury expire before reaching the hospital. Management of TTAL depends on hemodynamic condition of the patient, gravity of the aortic lesion, and presence of associated injuries.

4 TEVAR for traumatic thoracic aortic lesions TEVAR number one option to treat thoracic aortic lesions, because of better perioperative outcomes compared with open repair. Mainly small patient series, focusing on perioperative mortality and short-term outcome. Other issues such as timing of aortic repair or management of the LSA slightly unaddressed.

5 Aims of the study To evaluate the mortality, stroke risk, and paraplegia for patients with TTAL treated with TEVAR compared to open repair. To assess the impact of left subclavian artery (LSA) coverage. To focus on both on short- and long-term outcome.

6 Search strategy and inclusion of papers

7 Trial and patient characteristics 74 included papers describing endovascular repair of TTAL in 1882 patients. Mean age 40 yrs, 73 % male. ISS reported in 40 studies (n= 1091); median ISS 40.1 (IQR 6.1). Sample sizes of treated patients ranged from No RCT s or prospective cohort studies.

8 Trial and patient characteristics Two studies with prospectively obtained data (n= 64), 72 studies with retrospectively obtained data (n=1818). Methodological quality of papers moderate. MINORS score averaged 9.2 (range 5-13; SD 1.8) out of 16 for non-comparative studies and 15.5 (range 12-19; SD 1.6) out of 24 for comparative studies. Twenty-one of the 74 papers were studies comparing TEVAR with open repair for TTAL, describing 516 TEVAR cases and 801 conventionally treated patients.

9 Overall results for TEVAR Early mortality 7.5% (74 studies, 1882 TEVAR patients) and correlated with the ISS (Spearman's rank correlation coefficient 0.395, P=0.01). Not affected by the methodological quality (MINORS score) of the studies (Pearson correlation 0.199, P=0.341). No correlation between median inclusion year per study and early mortality after TEVAR (Spearman's rank correlation coefficient , P=0.696).

10 Overall results for TEVAR Paraplegia Described in all but two studies (n= 1822). Averaged at 0.4 % (n=7). Stroke Reported in 68 of 74 studies (Table 2; n= 1672 patients). 25 of 1672 patients (1.5%) suffered from a new-onset stroke.

11 LSA overstenting and complications

12 Stroke in relation to LSA overstenting 29 studies reported outcome of stroke after TEVAR (n = 681 patients) and status of LSA vascularization. Stroke rate in overstented LSA group 2.0 % (n=6/293) and in uncovered LSA group 1.3 % (n=5/400) (P= 0.28).

13 Stent related complications during follow-up

14 Early mortality rate of TEVAR vs conventional open repair TEVAR (n=496), open repair (n=776)

15 Paraplegia rate of TEVAR vs conventional open repair TEVAR (n=496), open repair (n=776)

16 Stroke rate of TEVAR vs conventional open repair TEVAR (n=418), open repair (n=702)

17 Quality of meta-analysis Quality of systematic review and meta-analysis directly related to quality of original papers. Lack of methodologically sound papers weakens strength of conclusions drawn from meta-analysis. Inclusion of mainly case series in this review associated with marked risk of selection bias. Most studies failed to achieve high MINORS score. None of the studies did prospective calculation of the study size. Mostly, endpoints not clearly defined or described. Failure to report follow up undermines quality of long term data. Papers comparing TEVAR to open repair for TTAL often used historical surgical control groups or compared heterogeneous groups. Several papers reporting large national databank data or endovascular registries were excluded from our meta-analysis because of overlapping data...

18 Conclusions TTAL can be treated endovascularly with low mortality and (neurological) morbidity. LSA coverage does not increase the risk of neurological complications, but is associated with a moderate risk of left arm ischemia. Long term stent related complications are rare, but the available data is limited.

19 Acknowledgements Kees-Pieter van der Zee Freek van Brussel Tryfon Vainas Maarten van der Laan Ben Saleem Paul van Schaik Ignace Tielliu Bas Wallis de Vries Thank you for your attention!