The Use of Thoracic Endovascular Stent Grafting in Acute Aortic Tragedies as Compared to Open Surgical Repair Tyler J. Wallen, BA, Wilson Y. Szeto, MD,

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The Use of Thoracic Endovascular Stent Grafting in Acute Aortic Tragedies as Compared to Open Surgical Repair Tyler J. Wallen, BA, Wilson Y. Szeto, MD, Nimesh Desai, MD, Nishtha Sodhi, BS,Patrick Moeller, BS, Alberto Pocchetino, MD, Joseph E. Bavaria, MD The University of Pennsylvania Health System

Introduction Since its introduction, the use of thoracic endovascular repair (TEVAR) for indications other than degenerative aneurysms has continually grown The mortality and morbidity associated with open surgical repair of a ruptured aorta or an aortic transection is considerably high The inherent danger of these open surgical procedures has caused surgeons to look to TEVAR as a possible, safer alternative The purpose of this study is to compare our center’s experience to a group of historical controls identified in the literature

Introduction Rupture is defined here as free rupture of an aortic aneurysm distal to the left subclavian artery Transection is defined here as a traumatic tear of the aorta distal to the left subclavian artery From October 2004 to February 2009, 23 patients meeting above criteria were treated with endovascular repair at the University of Pennsylvania

Demographics and Clinical Features FeatureRuptureTransection N1211 Age74 +/ /- 20 Gender (M:F)9:35:6 Cerebrovascular Disease3 (25%)1 (9%) CVA2 (17%)0 (0%) Dyslipidemia3 (25%)1 (9%) Diabetes5 (42%)1 (9%) HTN11 (92%)5 (45%) History of Smoking0 (0%)1 (9%) PreOp Creat1.2 +/ /- 0.3 Renal Failure0 (0%) with dialysis0 (0%) Arrhythmia4 (33%)0 (0%)

Results Primary endpoints were mortality at discharge, mortality at 1 year, paraplegia, paraparesis and permanent stroke Secondary endpoints included length of stay, myocardial infarction, reoperation for bleeding events, unresolved endoleak and renal failure

Results: Mortality and Paralysis RuptureTransection Sample Size1211 Discharge Mortality3 (25%)4 (36%) 1 Year Mortality5 (42%)5 (45%) Overall Complications9 (75%)10 (90%) Paralysis0 (0%) Paraparesis/Paraplegia2 (17%)1 (9%) Permanent Stroke2 (17%)1 (9%)

Results: Continued RuptureTransection Sample Size1211 Length of Stay27 +/- 29 Myocardial Infarction1 (8%)1 (9%) Reoperation for Bleeding1 (8%)2 (18%) Atrial Fibrillation3 (25%)0 (0%) Renal Failure0 (0%)2 (18%) with dialysis0 (0%)1 (9%) Unresolved Endoleak0 (0%)

Results: Continued Cambria, et. al, working with the GORE-TAG investigators, in their study of TEVAR for acute aortic events, identified 800 open surgical controls through surveys of the literature over the last 15 years The endovascular cohort in this study was compared to those surgical controls with respect to mortality and paraplegia

PresentationNMortality Surgical Mortality (n = 800)p-Value Rupture123 (25%)193 (24%)0.24 Transection114 (36%)0.132 TEVAR vs. Open Surgical Repair P-Values are calculated as adjusted, mid-p exact

TEVAR vs. Open Surgical Repair P-Values are calculated as adjusted, mid-p exact PresentatonN Mortality or Paraplegia Surgical Mortality or Paraplegiap-Value Rupture1242%30%0.2 Dissection2917%0.4

Conclusion Thoracic endovascular stent grafting is a safe alternative to open surgical repair of aortic ruptures and aortic transections, with outcomes that are not statistically different from open surgical repair. No statistical difference is observed between open surgical repair and endovascular therapy for aortic ruptures or transections. However, the minimally invasive nature of TEVAR may make it a superior choice. Additional studies are needed to elucidate the differences between endovascular and open surgical repair of aortic catastrophes.