OPEN REOPERATIONS FOR COMPLICATIONS OF ENDOVASCULAR AORTIC PROCEDURES: TIP OF THE ICEBERG?
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1 OPEN REOPERATIONS FOR COMPLICATIONS OF ENDOVASCULAR AORTIC PROCEDURES: TIP OF THE ICEBERG? NICHOLAS T. KOUCHOUKOS, MD DIVISION OF CARDIOVASCULAR AND THORACIC SURGERY MISSOURI BAPTIST MEDICAL CENTER ST. LOUIS, MISSOURI, USA
2 NO DISCLOSURES
3 SECONDARY OPEN AORTIC PROCEDURES (SOAP) BACKGROUND RATE OF THORACIC ENDOVASCULAR AORTIC REPAIR (TEVAR) HAS INCREASED DRAMATICALLY OVER THE PAST TWO DECADES
4 PREVALENCE OF OPEN SURGERY AND TEVAR FOR THORACIC ANEURYSM AND DISSECTION Wang et al. JVascSurg 2018; 67: 16-49
5 SECONDARY OPEN AORTIC PROCEDURES (SOAP) BACKGROUND RATE OF THORACIC ENDOVASCULAR AORTIC REPAIR (TEVAR) HAS INCREASED DRAMATICALLY OVER THE PAST TWO DECADES TEVAR CHARACTERIZED BY SUBSTANTIAL NEED FOR REINTERVENTIONS (11-15% IN RECENT SERIES)
6 SECONDARY OPEN AORTIC PROCEDURES (SOAP) BACKGROUND RATE OF THORACIC ENDOVASCULAR AORTIC REPAIR (TEVAR) HAS INCREASED DRAMATICALLY OVER THE PAST TWO DECADES TEVAR CHARACTERIZED BY SUBSTANTIAL NEED FOR REINTERVENTIONS (11-15% IN RECENT SERIES) OPEN REOPERATION INDICATED WHEN ENDOVASCULAR OPTIONS FEASIBLE NOT
7 SECONDARY OPEN AORTIC PROCEDURES (SOAP) BACKGROUND RATE OF THORACIC ENDOVASCULAR AORTIC REPAIR (TEVAR) HAS INCREASED DRAMATICALLY OVER THE PAST TWO DECADES TEVAR CHARACTERIZED BY SUBSTANTIAL NEED FOR REINTERVENTIONS (11-15% IN RECENT SERIES) OPEN REOPERATION INDICATED WHEN ENDOVASCULAR OPTIONS NOT FEASIBLE NUMBER OF SECONDARY OPEN AORTIC OPERATIONS (SOAP) LIKELY TO INCREASE OVER TIME
8 SOAP AFTER TEVAR COMPLICATIONS FOLLOWING TEVAR THAT REQUIRE OPEN OPERATION ENDOLEAK ANEURYSM EXPANSION OR RUPTURE RETROGRADE AORTIC DISSECTION FISTULA FORMATION STENT GRAFT INFECTION STENT GRAFT FRACTURE, COLLAPSE, MIGRATION OR EROSION
9 SOAP AFTER TEVAR META-ANALYSIS OF SECONDARY OPEN AORTIC PROCEDURES FOLLOWING TEVAR Gambardella et al. J. Am heart Assoc 2017;13: PUBLICATIONS SUITABLE FOR ANALYSIS ( ) 330 SECONDARY OPEN PROCEDURES MEAN AGE 62 YEARS 61% MALE 35% PROCEDURES NON-ELECTIVE MEAN INTERVAL BETWEEN TEVAR AND SOAP = 20 MONTHS (.3-62 MONTHS)
10 J. Am heart Assoc 2017;13:1-20
11 SOAP AFTER TEVAR EARLY MORTALITY OPERATIVE OUTCOMES NUMBER OF STUDIES WITH AVAILABLE DATA (TOTAL = 15) NUMBER OF PATIENTS 10.6% (4%-20%) MORBIDITY STROKE 5.1% PARAPLEGIA 8.3% PULMONARY 19.0% RENAL 15.8% CARDIAC 5.7% BLEEDING 5.0% J. Am heart Assoc 2017;13:1-20
12 SOAP AFTER TEVAR % EARLY MORTALITY ACCORDING TO PATHOLOGY AT INDEX TEVAR 40% 33% 0.00% 8.50% ANEURYSM N=71 1% DISSECTION N=108 FISTULA N=5 AORTIC TRANSECTION N=9 J. Am heart Assoc 2017;13:1-20
13 SOAP AFTER TEVAR 100% EARLY MORTALITY ACCORDING TO INDICATION FOR SOAP 90% 80% 70% 60% 50% 40% 30% 33% 20% 15% 10% 0% 2% 1% ENDOLEAK n=93 UNSTABLE ANEURYSM n= % 4% RTAD n=53 INFECTION n=23 FISTULA n=27 MISC n=6 J. Am heart Assoc 2017;13:1-20
14 J. Amer Heart Assoc
15 SOAP AFTER TEVAR Open Descending Thoracic or Thoracoabdominal Aortic Approaches for Complications of Endovascular Aortic Procedures: 19-year Experience (Spiliotopoulos, Coselli et al. JTCVS 2018;155:10 18) 45 PATIENTS AFTER TEVAR* MEAN AGE; 54 years 61% MALE 67% CHRONIC DISSECTION 38% MARFAN OR LOEYS-DIETZ SYNDROME MEDIAN INTERVAL BETWEEN TEVAR AND SOAP = 11 MONTHS (2-33 MONTHS) 57% HAD SOAP > 1 YEAR AFTER TEVAR * PATIENTS WITH RETROGRADE AORTIC DISSECTION NOT INCLUDED
16 INCREASE IN NUMBER OF OPEN REPAIRS AFTER ENDOVASCULAR AORTIC REPAIR JTCVS 2018;155:10 18
17 SOAP AFTER TEVAR EARLY MORTALITY OPERATIVE OUTCOMES 6.7% MORBIDITY STROKE 0 SPINAL CORD INJURY 7% PULMONARY 22% RENAL 4% CARDIAC 13% LATE MORTALITY* 33% 64% IN PATIENTS WITH INFECTION * MEDIAN FOLLOW-UP=36 MONTHS JTCVS 2018;155:10 18
18 SOAP AFTER TEVAR TEVAR IN PATIENTS WITH MARFAN SYNDROME (BÖCKLER ET AL, GEFÄßCHIRURGIE 2017;22: S51-57) 7 PUBLICATIONS SUITABLE FOR ANALYSIS 72 PATIENTS 4% EARLY MORTALITY 20% SUBSEQUENT ENDOVASCULAR PROCEDURE 22% SUBSEQUENT OPEN AORTIC PROCEDURE 15% LATE MORTALITY AT MEAN FOLLOW-UP OF 32 MONTHS
19 Conclusions AS THE NUMBER OF TEVAR PROCEDURES INCREASES, THE NUMBER OF SECONDARY OPEN AORTIC PROCEDURES WILL LIKELY INCREASE.
20 Conclusions AS THE NUMBER OF TEVAR PROCEDURES INCREASES, THE NUMBER OF SECONDARY OPEN AORTIC PROCEDURES WILL LIKELY INCREASE. ALTHOUGH < 20% OF PATIENTS UNDERGOING TEVAR HAVE CHRONIC AORTIC DISSECTION, IT IS THE MOST PREVALENT UNDERLYING PATHOLOGIC CONDITION REQUIRING SECONDARY OPEN AORTIC SURGERY (>50-60% OF PROCEDURES)
21 Conclusions AS THE NUMBER OF TEVAR PROCEDURES INCREASES, THE NUMBER OF SECONDARY OPEN AORTIC PROCEDURES WILL LIKELY INCREASE. ALTHOUGH < 20% OF PATIENTS UNDERGOING TEVAR HAVE CHRONIC AORTIC DISSECTION, IT IS THE MOST PREVALENT UNDERLYING PATHOLOGIC CONDITIONREQUIRING SECONDARY OPEN AORTIC SURGERY (>50-60% OF PROCEDURES) THE PERCENTAGE OF PATIENTS WITH MARFAN SYNDROME UNDERGOING SOAP (31% & 38% IN 2 SERIES) IS ALSO INORDINATELY HIGHER THAN THE PERCENTAGE OF PATIENTS WHO UNDERGO TEVAR
22 Conclusions AS THE NUMBER OF TEVAR PROCEDURES INCREASES, THE NUMBER OF SECONDARY OPEN AORTIC PROCEDURES WILL LIKELY INCREASE. ALTHOUGH < 20% OF PATIENTS UNDERGOING TEVAR HAVE CHRONIC AORTIC DISSECTION, IT IS THE MOST PREVALENT UNDERLYING PATHOLOGIC CONDITION REQUIRING SECONDARY OPEN AORTIC SURGERY (>50-60% OF PROCEDURES) THE PERCENTAGE OF PATIENTS WITH MARFAN SYNDROME UNDERGOING SOAP (31% & 38% IN 2 SERIES) IS ALSO INORDINATELY HIGHER THAN THE PERCENTAGE OF PATIENTS WHO UNDERGO TEVAR SOAP FOR PATIENTS WITH AORTIC DISSECTION IS ASSOCIATED WITH THE LOWEST EARLY MORTALITY (1%); INFECTION AND/OR FISTULA WITH THE HIGHEST (30-40%)
23 Conclusions AS THE NUMBER OF TEVAR PROCEDURES INCREASES, THE NUMBER OF SECONDARY OPEN AORTIC PROCEDURES WILL LIKELY INCREASE. ALTHOUGH < 20% OF PATIENTS UNDERGOING TEVAR HAVE CHRONIC AORTIC DISSECTION, IT IS THE MOST PREVALENT UNDERLYING PATHOLOGIC CONDITION REQUIRING SECONDARY OPEN AORTIC SURGERY (>50-60% OF PROCEDURES) THE PERCENTAGE OF PATIENTS WITH MARFAN SYNDROME UNDERGOING SOAP (31% & 38% IN 2 SERIES) IS ALSO INORDINATELY HIGHER THAN THE PERCENTAGE OF PATIENTS WHO UNDERGO TEVAR SOAP FOR PATIENTS WITH AORTIC DISSECTION IS ASSOCIATED WITH THE LOWEST EARLY MORTALITY (1%); INFECTION AND/OR FISTULA WITH THE HIGHEST (30-40%) THE 2- TO 3- YEAR TOTAL MORTALITY AFTER SOAP IS APPROXIAMETELY 30%, AND ½ OF DEATHS ARE AORTIC RELATED
24 Conclusions AS THE NUMBER OF TEVAR PROCEDURES INCREASES, THE NUMBER OF SECONDARY OPEN AORTIC PROCEDURES WILL LIKELY INCREASE. ALTHOUGH < 20% OF PATIENTS UNDERGOING TEVAR HAVE CHRONIC AORTIC DISSECTION, IT IS THE MOST PREVALENT UNDERLYING PATHOLOGIC CONDITION REQUIRING SECONDARY OPEN AORTIC SURGERY (>50-60% OF PROCEDURES) THE PERCENTAGE OF PATIENTS WITH MARFAN SYNDROME UNDERGOING SOAP (31% & 38% IN 2 SERIES) IS ALSO INORDINATELY HIGHER THAN THE PERCENTAGE OF PATIENTS WITH THE SYNDROME WHO UNDERGO TEVAR SOAP FOR PATIENTS WITH AORTIC DISSECTION IS ASSOCIATED WITH THE LOWEST EARLY MORTALITY (1%); INFECTION AND/OR FISTULA WITH THE HIGHEST (30-40%) THE 2 TO 3 YEAR TOTAL MORTALITY AFTER SOAP IS APPROXIAMETELY 30%, AND ½ OF DEATHS ARE AORTIC RELATED SOAP IS PERFORMED MORE THAN ONE YEAR AFTER TEVAR IN 50% OF PATIENTS; STRINGENT LONG TERM FOLLOWUP IS ESSENTIAL
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