Influence of Oversizing on Outcome in Thoracic Endovascular Aortic Repair

Abstract

Purpose: To investigate the influence of stent-graft oversizing on device-related complications after thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm (TAA).

Methods: The study cohort was composed of patients enrolled in 4 clinical trials of the TAG thoracic stent-graft. A total of 337 TAA patients (222 men; mean age 72 years) treated in these trials had sufficient data for analysis of oversizing and post-procedure mortality and complications, such as endoleak, migration, rupture, and reinterventions. Mean oversizing at the proximal landing zone was 14.6% (range −3.4% to 39.7%). Patients were stratified based on the percentage of oversizing: <10% (n=85, group 1), 10%–20% (n=188, group 2), and >20% (n=64, group 3).

Results: Patients in group 1 had significantly larger preoperative proximal aortic diameters (32.6 vs. 31.3 vs. 28.2 mm, respectively; p<0.001) and neck lengths (6.9 vs. 5.8 vs. 5.2 cm (p=0.035). Overall, type I endoleak was the most frequent complication during the first 30 days of follow-up (35, 10.4%), but the incidences did not differ among the 3 groups (10.6% vs. 11.2% vs. 7.8%, respectively; p=0.809). Over a mean follow-up of 41.8±20.7 months, there were no significant differences in the occurrence of device-related complications among the groups, though the incidence of type I endoleaks was lower in group 2 (9.4% vs. 3.2% vs. 7.8%, respectively; p=0.073). Cox proportional hazards modeling showed no difference in the time to type I endoleak among oversizing groups [group 1 vs. 2: HR 1.24, 95% CI 0.65 to 2.36 (p=0.509) and group 3 vs. 2: HR 1.24, 95% CI 0.60 to 2.60 (p=0.562)].

Conclusion: The percentage of oversizing did not significantly affect the incidence of device-related complications after TEVAR for TAA. Although oversizing may enhance the radial force and help maintain a good proximal seal, additional oversizing seemed not to improve the overall outcome in this analysis. The current guidelines regarding stent-graft oversizing for TAA seem appropriate, though the correct percentage remains to be determined

Keywords

thoracic aortic aneurysm thoracic endovascular aortic aneurysm repair stent-graft oversizing device-related complications endoleak migration branch vessel occlusion rupture mortality reintervention

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References

Bavaria

Appoo

Makaroun

. Endovascular stent grafting versus open surgical repair of descending thoracic aortic aneurysms in low-risk patients: a multicenter comparative trial. J Thorac Cardiovasc Surg. 2007;133:369–377.

Cambria

Crawford

Cho

; GORE TAG Investigators. A multicenter clinical trial of endovascular stent graft repair of acute catastrophes of the descending thoracic aorta. J Vasc Surg. 2009;50:1255–1264. e1–4.

Makaroun

Dillavou

Wheatley

. Five-year results of endovascular treatment with the Gore TAG device compared with open repair of thoracic aortic aneurysms. J Vasc Surg. 2008;47:912–918.

Makaroun

Dillavou

Kee

. Endovascular treatment of thoracic aortic aneurysms: results of the phase II multicenter trial of the GORE TAG thoracic prosthesis. J Vasc Surg. 2005;41:1–9.

Leurs

Harris

Buth

. Secondary interventions after elective endovascular repair of degenerative thoracic aortic aneurysms: results of the European Collaborators Registry (EUROSTAR). J Vasc Interv Radiol. 2007;18:491–495.

Canaud

Alric

Laurent

. Proximal fixation of thoracic stent-grafts as a function of oversizing and increasing aortic arch angulation in human cadaveric aortas. J Endovasc Ther. 2008;15:326–334.

Wyss

Dick

Brown

. The influence of thrombus, calcification, angulation, and tortuosity of attachment sites on the time to the first graft-related complication after endovascular aneurysm repair. J Vasc Surg. 2011;54:965–971.

Resch

Malina

Lindblad

. The impact of stent design on proximal stent-graft fixation in the abdominal aorta: an experimental study. Eur J Vasc Endovasc Surg. 2000;20:190–195.

Mohan

Laheij

Harris

. Risk factors for endoleak and the evidence for stent-graft oversizing in patients undergoing endovascular aneurysm repair. Eur J Vasc Endovasc Surg. 2001;21:344–349.

10.

van Prehn

Schlösser

Muhs

. Oversizing of aortic stent grafts for abdominal aneurysm repair: a systematic review of the benefits and risks. Eur J Vasc Endovasc Surg. 2009;38:42–53.

11.

Lin

Kratzberg

Raghavan

. Role of aortic stent graft oversizing and barb characteristics on folding. J Vasc Surg. 2012;55:1401–1409.

12.

Leurs

Bell

Degrieck

. Endovascular treatment of thoracic aortic diseases: combined experience from the EUROSTAR and United Kingdom Thoracic Endograft registries. J Vasc Surg. 2004;40:670–680.

13.

Figueroa

Taylor

Chiou

. Magnitude and direction of pulsatile displacement forces acting on thoracic aortic endografts. J Endovasc Ther. 2009;16:350–358.

14.

van Prehn

Bartels

Mestres

. Dynamic aortic changes in patients with thoracic aortic aneurysms evaluated with electrocardiography-triggered computed tomographic angiography before and after thoracic endovascular aneurysm repair: preliminary results. Ann Vasc Surg. 2009;23:291–297.

15.

van Keulen

Moll

Barwegen

. Pulsatile distension of the proximal aneurysm neck is larger in patients with stent graft migration. Eur J Vasc Endovasc Surg. 2010;40:326–331.

16.

Jonker

Schlösser

Geirsson

. Endograft collapse after thoracic endovascular aortic repair. J Endovasc Ther. 2010;17:725–734.

17.

Makaroun

Deaton

. Is proximal aortic neck dilatation after endovascular aneurysm exclusion a cause for concern? J Vasc Surg. 2001;33:S39–45.

18.

van Keulen

van Prehn

Prokop

. Dynamics of the aorta before and after endovascular aneurysm repair: a systematic review. Eur J Vasc Endovasc Surg. 2009;38:586–596.