Thoracic endovascular aortic repair (TEVAR) is now recommended as primary intervention for type B aortic dissection (TBAD), traumatic rupture and thoracic aortic aneurysms with anatomy that allows for endovascular repair(1). Concurrently a rise in thoracic disease incidence has been recorded in the last decade, though this is likely attributed to improved emergency diagnostics, as well as improved survival of cardiac comorbidities (2-4). Due to the increasing usage of TEVAR long-term follow-up studies are warranted in current guidelines.

Patients undergoing TEVAR were consecutively included from 1999-2019. Thoracic aortic disease includes thoracic aortic aneurysms, aortic dissection, traumatic rupture, penetrating aortic ulcer (PAU) and intramural hematoma (IMH). Our prospective database recorded baseline characteristics, endoleak or aneurysm growth and death. Patients were included at time of treatment and censored at death, or first reintervention depending on the analysis. Primary endpoint was all-cause death, secondary endpoint was reintervention. Survival and failure analysis were done using StataIC 16.0® and truncated at 15 years of follow-up.

256 patients were included - 63% were men. Their mean age at intervention was 66.2 ± 14.5 years and they were followed for a mean of 5.2 ± 4.5 years. Indications for TEVAR were acute aortic syndrome 40.6%, chronic aortic disease 44.5%, and traumatic rupture in 14.8 %. Technical success was seen in 94.1 % of the operations, and the left subclavian artery was covered in 27.7%. 30-day mortality rate was 21.2% (22/104) and 1.75% (2/114) (p<0.001) for urgent and elective patients, respectively. Twelve patients (4.7%) died within 24 hours of treatment. In total 112 (43.8%) deaths were recorded, during follow-up. Using traumatic cases as reference and adjusted for age and sex at intervention, we found slightly decreased HR 0.89 (95% CI; 0.39-2.1) p=0.8 for Chronic conditions, HR 1.4 (95% CI; 0.6-3.2) p=0.42 for AAS (Figure 1). 29 patients had reinterventions (11.3 % (95% confidence interval: 7.7-15.9)), aneurysms accounted for 62.1% of all reinterventions. 24 (82.8%) reinterventions occurred within the first 5 years.

In this long-term prospective TEVAR study spanning two decades of TEVAR intervention, we observed more than 12 times higher 30-day mortality rate for patients treated for AAS compared to the chronic aortic group. 50% higher age-adjusted overall mortality in the long term for acutely treated patients, although not reaching statistical significance. The need for reintervention was just 11% with more than 80% occurring within the first 5 years. Our long term data shows that TEVAR is a long-lasting and minimally invasive treatment for a series of thoracic aortic diseases, however, because of the limited patient volumes and complicated setup to offer it 24/7, it should be limited to centralized aortic centres where the infrastructure of the prehospital care and transportation allows it.

1. Riambau V, Böckler D, Brunkwall J, Cao P, Chiesa R, Coppi G, et al. Editor's Choice - Management of Descending Thoracic Aorta Diseases: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2017;53(1):4-52. 2. Martin G, Patel N, Grant Y, Jenkins M, Gibbs R, Bicknell C. Antihypertensive medication adherence in chronic type B aortic dissection is an important consideration in the management debate. Journal of vascular surgery. 2018;68(3):693-9.e2. 3. Zoli S, Etz CD, Roder F, Mueller CS, Brenner RM, Bodian CA, et al. Long-term survival after open repair of chronic distal aortic dissection. Ann Thorac Surg. 2010;89(5):1458-66. 4. Olsen PS, Parvaiz I, Overgaard O, Carranza CA, Kure HH, Bendixen A. [Surgery of the thoracic aorta in Denmark 1997-2003]. Ugeskr Laeger. 2007;169(6):510-3.