O-149 - PATIENT CHARACTERISTICS, CLINICAL PRESENTATION, LOCATION, AND OUTCOMES OF SACCULAR ANEURYSMS OF THE DESCENDING THORACIC AORTA IN THE VASCULAR QUALITY INITIATIVE

TOPIC:
Thoraco-abdominal Aortic Disease
AUTHORS:
Rastogi V. (Beth Israel Deaconess Medical Center ~ Boston ~ Netherlands) , Patel P. (Beth Israel Deaconess Medical Center ~ Boston ~ Netherlands) , Solomon Y. (Beth Israel Deaconess Medical Center ~ Boston ~ Netherlands) , Anjorin A. (Beth Israel Deaconess Medical Center ~ Boston ~ Netherlands) , Marcaccio C. (Beth Israel Deaconess Medical Center ~ Boston ~ Netherlands) , Scali S. (Division of Vascular Surgery and Endovascular Therapy, University of Florida ~ Gainesville ~ United States of America) , Beck A. (Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham ~ Birmingham ~ United States of America) , Lo R. (Division of Vascular Surgery and Endovascular Surgery, Brown University Medical Center ~ Providence ~ United States of America) , Verhagen H. (Erasmus University Medical Center ~ Rotterdam ~ Netherlands) , Schermerhorn M. (Beth Israel Deaconess Medical Center ~ Boston ~ Netherlands)
Introduction:
Current guidelines suggest to treat saccular shaped aneurysms at smaller diameters than fusiform aneurysms, despite lack of evidence to support this practice.1,2 Furthermore, literature on the natural history of saccular thoracic aortic aneurysms (TAA) is limited too, although saccular morphology is most prevalent at this level.3 The aim of this study was to examine differences in presentation, treatment, and outcomes between saccular TAA and fusiform TAA in the descending thoracic aorta.
Methods:
All Vascular Quality Initiative (VQI) patients undergoing thoracic endovascular aneurysm repair (TEVAR) for TAA from 2003-2021 were reviewed. Patients with non-degenerative TAA including post-dissection TAA's were excluded, as were patients with disease involving the ascending aorta or aortic arch. Thereafter, patients were stratified by urgency: elective vs. non-elective (symptomatic/ruptured). Demographics, comorbidities, anatomical/procedural-characteristics, and outcomes between fusiform TAA and saccular TAA were compared. Cumulative distribution curves were used to plot the proportion of patients who underwent non-elective repair according to sex-stratified aortic diameter.
Results:
Among 1,967 patients who underwent TEVAR of TAA, 675 (35%) had saccular morphology. There were 1,282 elective patients (34% saccular TAA) and 674 with symptomatic/ruptured (38% saccular TAA) presentation. Saccular TAA had lower rates of prior aortic surgery compared with fusiform TAA (25% vs. 40%, p<.001), specifically due to lower rates of prior open ascending aortic repair (3.6% vs. 13%, p<.001). (Table) Within the elective cohort, saccular TAAs were treated at smaller diameters (54mm [IQR 45, 62] vs. 61mm [IQR 55, 65], p<.001), had more proximal sealing zones (zone-2 or proximal: 23% vs. 14%, p<.001) and more frequently underwent adjunctive left subclavian artery (LSA) management (21% vs. 12%, p<.001). Saccular TAA had similar postoperative morbidity and mortality; however it was associated with lower risk of spinal cord-ischemia (0.3% vs. 3.3%, p=.003) compared with fusiform TAA. Saccular TAA patients had higher 5-year mortality (HR 1.6 [95%CI: 1.1-2.2], p=.010). Among symptomatic/ruptured saccular TAAs, patients were treated at smaller diameters (55mm [IQR 45, 70] vs. 62mm [IQR 55, 73], p<.001). Additionally, 57% of symptomatic/ruptured saccular TAA patients presented with diameters <60mm and 24% <45mm, versus 40% and 9.5% of symptomatic/ruptured fusiform-TAA patients (p<.001). Furthermore, within symptomatic/ruptured fusiform TAAs, women presented at smaller diameters compared with men, whereas there was no difference in aortic diameter for saccular TAAs. (Figure) Treatment of acute saccular TAA showed similar postoperative mortality and major complications compared with acute fusiform TAA. After adjusting for age and sex, there was no difference in overall survival between both acutely treated aneurysm morphologies.
Conclusion:
Within the VQI, saccular TAAs present as symptomatic/ruptured TAA at smaller diameters than fusiform TAAs, supporting the current idea that saccular TAAs warrant treatment at smaller diameters than fusiform TAAs. Among symptomatic/ruptured fusiform TAAs, women presented at smaller diameters compared with men. There was no influence of sex on aortic diameter at presentation for symptomatic/ruptured saccular TAAs.
References:
1. Committee W, Riambau V, Böckler D, Brunkwall J, Cao P, Chiesa R, et al. Editor's Choice - Management of Descending Thoracic Aorta Diseases: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg [Internet]. 2017;53(1):4-52. Available from: https://doi.org/10.1016/j.ejvs.2016.06.005 2. Upchurch GR, Escobar GA, Azizzadeh A, Beck AW, Conrad MF, Matsumura JS, et al. Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms. J Vasc Surg [Internet]. 2021;73(1):55S-83S. Available from: https://doi.org/10.1016/j.jvs.2020.05.076 3. Shang EK, Nathan DP, Boonn WW, Lys-Dobradin IA, Fairman RM, Woo EY, et al. A modern experience with saccular aortic aneurysms. J Vasc Surg [Internet]. 2013;57(1):84-8. Available from: http://dx.doi.org/10.1016/j.jvs.2012.07.002
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