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High mortality rates after both open surgical and endovascular thoracic aortic interventions in patients with end-stage renal disease.
J Vasc Surg. 2017 10; 66(4):991-996.JV

Abstract

BACKGROUND

Morbidity and mortality have improved with the evolution of endovascular techniques (thoracic endovascular aortic repair [TEVAR]) for thoracic aortic disease, but results after aortic intervention in patients with end-stage renal disease (ESRD) remain unclear. The objective of this study was to evaluate outcomes of open and endovascular descending thoracic aortic repair in dialysis-dependent patients.

METHODS

We identified 352 patients with ESRD on dialysis undergoing open repair (n = 136) or TEVAR (n = 216) of the thoracic aorta from 2005 to 2008 using the United States Renal Data System database. Acute presentation was defined as ruptured aneurysm, dissection, or traumatic injury; all other interventions were considered elective. End points were 30-day mortality, overall survival, rates of perioperative complications, and procedural trends over time. Between-group comparisons and survival analysis used standard statistical methods. Logistic regression and Cox regression were performed using multivariate analysis.

RESULTS

TEVAR subjects were older than those undergoing open repair (68.2 ± 11.5 vs 60.8 ± 13.2 years; P < .001); no other demographics differed. There were 303 patients who had thoracic or thoracoabdominal aneurysms; 47 (13.4%) were ruptured on presentation. There were 44 patients (12.5%) who had aortic dissection and 5 (1.4%) with aortic trauma. Overall 30-day mortality was 21.3% (n = 75), and it was greater for open repair (n = 41 [30.1%]) than for TEVAR (n = 34 [15.7%]; P = .002). Elective 30-day mortality for open repair (n = 27 [29.3%]) was also greater than for TEVAR (n = 24 [14.3%]; P = .005). Those with acute presentation trended toward higher mortality for open repair (n = 14 [31.8%] vs n = 10 [15.7%]; P = .17). Respiratory failure was higher for open repair (n = 69 [50.7%] vs n = 56 [25.9%]; P < .001); postoperative stroke was higher with TEVAR (n = 21 [9.7%] vs n < 10 [<7%]; P = .02). Estimated 1-year survival was 50% and did not differ between groups (44% for open repair, 53% for TEVAR). In multivariate analysis, TEVAR decreased odds of 30-day mortality compared with open repair (odds ratio, 0.41; 95% confidence interval, 0.24-0.71) but failed to demonstrate long-term survival advantage.

CONCLUSIONS

In ESRD patients, TEVAR provides short-term mortality benefits compared with open repair, but long-term mortality remains high regardless of treatment modality. Elective intervention for thoracic aortic disease in this population remains high risk and should be approached with caution.

Authors+Show Affiliations

Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa. Electronic address: liangnl@upmc.edu.Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.

Pub Type(s)

Comparative Study
Journal Article
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

28400216

Citation

Liang, Nathan L., et al. "High Mortality Rates After Both Open Surgical and Endovascular Thoracic Aortic Interventions in Patients With End-stage Renal Disease." Journal of Vascular Surgery, vol. 66, no. 4, 2017, pp. 991-996.
Liang NL, Yuo TH, Al-Khoury GE, et al. High mortality rates after both open surgical and endovascular thoracic aortic interventions in patients with end-stage renal disease. J Vasc Surg. 2017;66(4):991-996.
Liang, N. L., Yuo, T. H., Al-Khoury, G. E., Hager, E. S., Makaroun, M. S., & Singh, M. J. (2017). High mortality rates after both open surgical and endovascular thoracic aortic interventions in patients with end-stage renal disease. Journal of Vascular Surgery, 66(4), 991-996. https://doi.org/10.1016/j.jvs.2016.12.144
Liang NL, et al. High Mortality Rates After Both Open Surgical and Endovascular Thoracic Aortic Interventions in Patients With End-stage Renal Disease. J Vasc Surg. 2017;66(4):991-996. PubMed PMID: 28400216.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - High mortality rates after both open surgical and endovascular thoracic aortic interventions in patients with end-stage renal disease. AU - Liang,Nathan L, AU - Yuo,Theodore H, AU - Al-Khoury,Georges E, AU - Hager,Eric S, AU - Makaroun,Michel S, AU - Singh,Michael J, Y1 - 2017/04/08/ PY - 2016/10/01/received PY - 2016/12/27/accepted PY - 2017/4/13/pubmed PY - 2017/10/3/medline PY - 2017/4/13/entrez SP - 991 EP - 996 JF - Journal of vascular surgery JO - J Vasc Surg VL - 66 IS - 4 N2 - BACKGROUND: Morbidity and mortality have improved with the evolution of endovascular techniques (thoracic endovascular aortic repair [TEVAR]) for thoracic aortic disease, but results after aortic intervention in patients with end-stage renal disease (ESRD) remain unclear. The objective of this study was to evaluate outcomes of open and endovascular descending thoracic aortic repair in dialysis-dependent patients. METHODS: We identified 352 patients with ESRD on dialysis undergoing open repair (n = 136) or TEVAR (n = 216) of the thoracic aorta from 2005 to 2008 using the United States Renal Data System database. Acute presentation was defined as ruptured aneurysm, dissection, or traumatic injury; all other interventions were considered elective. End points were 30-day mortality, overall survival, rates of perioperative complications, and procedural trends over time. Between-group comparisons and survival analysis used standard statistical methods. Logistic regression and Cox regression were performed using multivariate analysis. RESULTS: TEVAR subjects were older than those undergoing open repair (68.2 ± 11.5 vs 60.8 ± 13.2 years; P < .001); no other demographics differed. There were 303 patients who had thoracic or thoracoabdominal aneurysms; 47 (13.4%) were ruptured on presentation. There were 44 patients (12.5%) who had aortic dissection and 5 (1.4%) with aortic trauma. Overall 30-day mortality was 21.3% (n = 75), and it was greater for open repair (n = 41 [30.1%]) than for TEVAR (n = 34 [15.7%]; P = .002). Elective 30-day mortality for open repair (n = 27 [29.3%]) was also greater than for TEVAR (n = 24 [14.3%]; P = .005). Those with acute presentation trended toward higher mortality for open repair (n = 14 [31.8%] vs n = 10 [15.7%]; P = .17). Respiratory failure was higher for open repair (n = 69 [50.7%] vs n = 56 [25.9%]; P < .001); postoperative stroke was higher with TEVAR (n = 21 [9.7%] vs n < 10 [<7%]; P = .02). Estimated 1-year survival was 50% and did not differ between groups (44% for open repair, 53% for TEVAR). In multivariate analysis, TEVAR decreased odds of 30-day mortality compared with open repair (odds ratio, 0.41; 95% confidence interval, 0.24-0.71) but failed to demonstrate long-term survival advantage. CONCLUSIONS: In ESRD patients, TEVAR provides short-term mortality benefits compared with open repair, but long-term mortality remains high regardless of treatment modality. Elective intervention for thoracic aortic disease in this population remains high risk and should be approached with caution. SN - 1097-6809 UR - https://www.unboundmedicine.com/medline/citation/28400216/High_mortality_rates_after_both_open_surgical_and_endovascular_thoracic_aortic_interventions_in_patients_with_end_stage_renal_disease_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0741-5214(17)30361-0 DB - PRIME DP - Unbound Medicine ER -