Eur J Cardiothorac Surg 2008;34:630-634. doi:10.1016/j.ejcts.2008.05.046
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
Endovascular repair of the thoracic aorta in octogenarians
Jacques Kpodonua,*,
Ourania Preventzab,
Venkatesh G. Ramaiaha,
Hani Shenniba,
Grayson H. Wheatley, IIIa,
Julio A. Rodriquez-Lopeza,
James Williamsa,
Edward B. Diethricha
a Arizona Heart Institute, Department of Cardiovascular and Endovascular Surgery, Phoenix, AZ, United States
b Bayhealth Medical Center, Department of Cardiac Surgery, Dover DE affiliated with University of Pennsylvania Health System, Philadelphia, PA, United States
Received 13 September 2007;
received in revised form 21 May 2008;
accepted 26 May 2008.
* Corresponding author. Address: Hoag Heart and Vascular Institute, Hoag Presbyterian Memorial Hospital, 1 Hoag Drive, PO box 6100, Newport Beach, CA 92658-6100, Unites States. Tel.: +1 602 266 2200; fax: +1 602 604 5020. (Email: jkpodonu{at}yahoo.com).
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Abstract
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Background: To evaluate the feasibility and safety of thoracic endografting in the octogenarian population. Methods: Between February 2000 and August 2005, 249 patients with a mean age of 69 ± 12.3 years (range 23–91) underwent thoracic endografting. Forty-four patients (27 males and 17 females) were octogenarians with a mean age of 84 ± 2.7 years. Indications for intervention included: atherosclerotic aneurysms (26/44, 59%), acute and chronic dissections (9/44, 20.5%), penetrating aortic ulcers (6/44, 14%) and contained rupture (3/44, 7%). Results: Endovascular repair was achieved in all octogenarian patients (44/44, 100%). Mean length of stay was 4.7 ± 3.6 days. Two cardiac-related deaths and 1 retrograde dissection death occurred (3/44, 7%). Complications included hemiparesis (n
= 2) with full recovery at discharge, groin hematoma (n
= 1), pneumonia (n
= 2) and stroke (n
= 1) [6/44, 11%]. Endoleaks were diagnosed in 3 patients [3/44, 7%] (2 type I, 1 type II) at 30-day follow-up. Two patients developed an endoleak beyond 30 days [2/44, 5%] (1 type I, 1 type II). Two re-interventions were necessary at 30 days (1 type I, 1 type II). Mean follow-up was 22 months and there were no device migrations or aortic ruptures. No statistical differences in overall mortality were noted between octogenarians and non-octogenarians at 30 days (7% vs 6%, p
= NS), 12 months (18% vs 13%, p
= NS) and 24 months (27% vs 15%, p
= NS). However, at 5 years post-procedure, octogenarians had a significantly higher overall mortality than non-octogenarians (32% vs 17%, p
= 0.038). Conclusions: Advanced age is not a contraindication to thoracic endografting with favorable short and mid-term outcomes compared to non-octogenarians.
Key Words: Octogenarian • Thoracic stent graft • Endovascular surgery
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1. Introduction
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Conventional open thoracic aortic surgical repair has demonstrated higher perioperative complication rates for elderly patients and age has been shown to be an independent risk factor for postoperative adverse effects following thoracic aortic surgery. Endovascular therapy for the management of thoracic aortic pathology is rapidly progressing and is a viable alternative to traditional open surgical repair. Due to the overall limited data available concerning the use of thoracic stent graft repair of descending thoracic aorta in older patients compared to the existing experience with open surgical repair, ongoing studies analyzing complications and outcomes for thoracic endografting are essential. Since older patients are often denied treatment due to the perception of increased surgical risk associated with the procedure we sought to analyze our institution's outcomes with respect to safety and efficacy with the treatment of various thoracic aortic pathologies in an octogenarian and a non-octogenarian cohort group using the Gore TAG excluder (W.L. Gore & associates, Flagstaff, AZ) endoluminal graft.
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2. Materials and methods
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A total of 249 consecutive patients with thoracic stenting were prospectively entered into our clinical database between February 2000 and August 2005. Mean age was 69 ± 12.3 years (range 23–91), with 147 males (59%) and 102 females (41%). Two groups were identified: those under the age of 80 (205/249, 82%) and those 80 years and older (44/249,17.7%). Patient demographics, associated comorbidities, clinical presentation, operative management with procedural details, reinterventions, complications and mortality were prospectively entered into a clinical database and reviewed for the purpose of this study as outlined in Tables 1–4
. Demographics of the octogenarian and non-octogenarian population are listed in Table 1. The mean age of the octogenarian group was 84 years (84 ± 2.7 years), 27 males and 17 females and the mean age for the group under 80 was 66 ± 11 years (23–79). For the octogenarian group the indications for intervention were the following: atherosclerotic aneurysms in 26 patients (26/44,60%), acute and chronic dissections in 9 (9/44,21%), penetrating aortic ulcers in 6 patients (6/44,14%) and contained ruptures in 3 patients (3/44, 6.8%). For the non-octogenarian group; thoracic aneurysms comprised of 84 patients (84/205, 41%),acute and chronic dissections 58 patients (5/205, 28%), penetrating aortic ulcers 24 patients (24/205,12%),contained ruptures in 10 patients (10/205, 5%) and a miscellaneous group of 29 patients (29/205,14%) which comprised of patients treated for coarctation native and recurrent, aortobronchial fistulas, anastomotic aneurysms and pseudoaneurysms from prior repair, and aortic transections. Common associated comorbidities in the study population are outlined in Table 2. In the octogenarian group hypertension was present in 34 patients (34/44, 77%), prior coronary artery bypass in 2 patients (2/44, 5%), prior myocardial infarct and percutaneous transluminal angioplasty in 4 patients (4/44, 9%), history of cerebrovascular accident (CVA) in 2 patients (2/44, 5%), chronic renal insufficiency in 15 patients (15/44, 34%) and chronic obstructive pulmonary disease (COPD) in 4 patients (4/44, 9%).Thirty-eight patients (38/44, 86.4%) were prior smokers. Comorbidities present in the non-octogenarian group (Table 2) included 155 patients (155/205, 76%) that were hypertensive,12 had history of coronary artery bypass (12/205, 6%),17 had prior myocardial infarct (17/205, 8%), history of CVA was present in 12 patients (12/205, 6%), renal insufficiency in 43 patients (43/205, 21%) and COPD in 40 patients (40/205, 20%). One hundred and fifty patients in the younger group were current or prior smokers.
2.1 Surgical technique
All patients were treated using the GORE TAG endoprosthesis (TAG; W.L. Gore, Flagstaff, AZ). The feasibility of placement of an endovascular stent graft was based on a preoperative CT angiography with patients offered the procedure if they had appropriate vascular anatomy. All procedures were performed under general anesthesia in the operating endovascular suite. A digital fixed C-arm image intensifier with subtraction angiography and roadmap capabilities was used. A small oblique suprainguinal incision was performed to expose the common femoral artery (CFA) and 5000 units of unfractionated heparin were given intravenously after the exposure. Intravascular ultrasound (IVUS) was occasionally performed through a 9 Fr sheath in the exposed CFA as well as an thoracic arch aortogram to determine the proximal and distal neck diameter, neck length and presence or absence of thrombus. During the endovascular repair, mean arterial pressure (MAP) was maintained at 70–80 mmHg with exception to the time of graft deployment (few seconds) where the systolic blood pressure (SBP) was lowered to 90 mmHg. Deployment of the endoluminal graft was performed under fluoroscopic visualization using the road map angiogram. Postoperative mean arterial pressure was maintained between 80 and 90 mmHg using vasopressors or vasodilators. Preoperative cerebrospinal fluid drainage was not required in any of the octogenarian patients. Two patients from the younger group required cerebrospinal fluid drainage prior to the procedure because of previous open abdominal aortic aneurysm, which is considered a high-risk marker for paraplegia with uneventful recovery. A CT scan of the chest and abdomen was performed prior to discharge to confirm satisfactory exclusion of thoracic aortic aneurysm as well as to rule out the presence of any endoleak. A scheduled postoperative CT scan was performed at 6 months and yearly thereafter per protocol for long-term surveillance of the endograft; however more frequent CT scans were performed if there was a complication requiring more urgent follow-up.
2.2 Statistical analysis
Statistical analysis was performed with SAS software (SAS version 8.1, SAS Institute; Cary, NC). Continuous variables are expressed as mean ± SD and categorical variables as percentages throughout the manuscript. Comparisons of continuous variables between groups were performed with unpaired Student's t-tests. Survival between groups was compared by the Kaplan–Meier method. A two-tailed p value less than 0.05 was considered statistically significant.
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3. Results
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Thoracic endostenting was performed successfully in all octogenarians and in all but one patient under the age of 80 where open conversion was performed due to misplacement of the graft. Results were determined to be significant using the 5% significance level. Measurements for quantitative variables are reported as mean ± standard error of the mean. Kaplan–Meier survival curves were evaluated for both groups. All patients with transections, aortobronchial fistulas, and pseudoaneurysms from prior surgery, recurrent and native coarctation belonged in the younger non-octogenarian age group. All pre-existing comorbid conditions were identical between the two groups (Table 2). Length of hospital stay and intraoperative blood loss was not statistically significant. The usage of total amount of contrast was higher in the younger group but was not statistically significant either. Complications including respiratory and neurological complications were few and similar between the two groups as outlined in Table 3. In the octogenarian group two patients suffered postoperative pneumonia and three neurological events. In the three neurological events two patients presented with paraparesis with full recovery at discharge and one patient with postoperative stroke. In the younger patient group three patients had postoperative stroke and a total of seven patients had spinal cord injury with permanent neurological deficit in two patients. At some point during the follow-up period of 60 months, a total of 38 endoleaks were identified in all 249 patients: five belonged to the octogenarian group (5/44, 11%); three early and two beyond the 30 days. A total of twelve reinterventions with an additional endoluminal graft (ELG) was required in all 249 patients. In the older group two reinterventions at 30 days were performed, one due to type I endoleak and the other one, due to type II endoleak. One octogenarian patient due to morphology of his thoracic aneurysm required subclavian-carotid bypass prior to aneurysm repair and 13 subclavian carotid bypasses were performed in the younger group prior to the endografting of the descending thoracic aorta. Postoperative arm claudication due to coverage of the left subclavian was present in a young patient who required post-subclavian carotid bypass.
The 30-day mortality was 7% in the older group (3/44 patients) vs 6% (12/205) in the younger group (not statistical significant, p
= NS). At 12 months and 24 months the mortality was 18% vs 13% (p
= NS), and 27% vs 15% (p
= NS), respectively. However, at 5-year post-procedure the octogenarians had a much higher overall mortality (14/44, 32%) than the non-octogenarians (35/205, 17%) as outlined in Table 4 and was found to be statistically significant (p
= 0.038) (Fig. 1
).
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Fig. 1. Kaplan–Meier survival curve comparing non-octogenarian group and the octogenarian group at time intervals of 1 month, 6 months, 1, 2, 3, 4 and 5 years, respectively.
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4. Discussion
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In patients who undergo major cardiovascular procedures, advanced age can be a predictor of increased morbidity and mortality. A risk factor analysis in 1220 consecutive patients from 1986 to 1998 undergoing thoracoabdominal aneurysm repair was performed by Coselli et al. [1] for patients undergoing an elective procedure and increased age was a strong predictor of operative mortality. Safi et al. [2] evaluated the outcome in patients 79 and older after open repair of thoracoabdominal or descending thoracic aneurysms and in their study, the 30-day mortality was reported to be 17% in patients at low risk and 50% in patients at high risk with emergency presentation, congestive heart failure or diabetes. The authors concluded that in elderly patients with appropriate selection, surgery can be undertaken with acceptable mortality and morbidity. In our study the 30-day mortality of 6.8% for thoracic endografting was significantly lower. Kawachi et al. [3] also reported a 14% mortality for thoracic aneurysm repair in selected octogenarians. The same authors [3,4] performed a comparative study of the natural history and operative results in patients older than 75 years with thoracic aortic aneurysms and concluded that patients 75 years and older with TAA should undergo an elective operation if the aneurysm diameter is larger than 6 cm and if the patient is asymptomatic and a good anatomico-surgical candidate as well as in good physical and social condition. In a large study of 1157 patients, Okita et al. [5] compare early- and long-term results of surgery for thoracic aortic aneurysms in patients over 70 years of age with those less than 70 years and reported that early- and long-term results for open thoracic aortic aneurysm repair in patients older than 70 years were less satisfactory compared with the younger group especially in subgroup who required emergency surgery.
Thoracic aortic endografting was initial described by Dake et al. [6] in the early 1990s.The application of this technology has significantly changed the treatment for patients with abdominal as well as thoracic aortic disease. The Eurostar collaborators investigated the early and late outcome after endovascular treatment of abdominal aortic aneurysm (EVAR) in octogenarians compared with patients aged <80 years [7] and concluded that EVAR might be considered when treating elderly patients. In their study the 30-day mortality was statistically significantly higher in the older than the younger group. In a comparative study reported by Ehrich et al. [8] open repair was compared with the endovascular repair and the 30-day mortality in the open repair group was 31% vs 10% in the endovascular group. The benefits and the favorable outcome in endovascular repair of different thoracic pathologies were also reported by other authors [9–11]. Despite satisfactory results with thoracic endografting the impact of age on patients requiring the use of this new technology is not fully evaluated. Eggebrecht et al. [12] evaluated the results of endovascular stent-graft placement for the treatment of patients with type B acute and chronic aortic dissection. In their study they revealed that poor preoperative health conditions as well as increased age were independent determinants of postinterventional mortality. Kern et al. [13] in a recent study also reported that endografting could be performed safely in elderly patients with no significant morbidity and mortality compared with younger patients. In their study female gender was associated with higher complication rate regardless of the age. Their study findings compared similarly to our own study findings. In our study there were no differences found between the two groups in terms of demographics and complications. Preoperative subclavian carotid bypass was performed more frequently in the younger patients than the octogenarians probably due to a more cautious approach regarding left upper arm symptoms in relation to younger age. Female to male ratio was equal in the 30-day mortality in the younger group with higher mortality of females in the octogenarian group. During the follow-up period the overall mortality at 30 days, 12 months and 24 months was not statistically significant between the two groups using Kaplan–Meier survival curves (Fig. 1); however at 5 years post-procedure the mortality in the octogenarian group almost doubled (31.8% vs 17.1%, p
= 0.038). The increased mortality at 5 years could be explained by the advanced age of the octogenarian patients who most likely died from their other comorbidities often associated with thoracic aortic pathologies rather than procedure related complications which we would expect to show up within the first 2 years post-procedure.
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5. Conclusion
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Increased age does not appear to be a risk factor for short- and mid-term morbidity and mortality for patients with thoracic endografting. Older patients do as well as the younger counterparts after endostenting of the thoracic aorta. Some of the limitations of our study include the fact that this was a retrospective study and not a randomized study; as such we appreciate that there are certain limitations that are associated with such a study. The rather small subpopulation of octogenarians undergoing thoracic endografting makes it difficult to enroll patients and conduct a randomized study to effectively answer the question of age; however, we conclude that octogenarians should be offered a less invasive approach of thoracic endografting to treat thoracic aortic pathologies.
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Appendix A
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Conference discussion
Dr M. Czerny (Vienna, Austria): Actually we have the same experience, that these old people do very well, even in the long term, if you fix their primary problem then, and if this is the only limitation for them, then you will have a smooth follow-up course.
Dr S. Schueler (Newcastle Upon Tyne, UK): Berlin, any difference?
Dr B. Zipfel (Berlin, Germany): Well, I can’t answer the question right because we didn’t select the patients according to age. I am wondering in your presentation that there was a slightly worse perioperative result in the group under 80. Is this because there is a different choice of the aneurysms, are there more difficult cases? In the patients under 80, I think that is a very important issue.
Dr Kpodonu: Actually we retrospectively looked at the data, so there was no selection bias. This is what we found. It is difficult to explain. Whether the younger ones had more difficult aneurysms, I don’t know. But this is what we found looking back at our data. So it is surprising. But the good news is that you can safely perform these procedures on octogenarians. If you look at our data again you will find out that 40% of those patients that we operated on were for acute emergencies: dissections, penetrating ulcers. So maybe that may have also a role to play.
Dr A. Haverich (Hannover, Germany): It looked like you confined your presentation to patients who got GORE stents only.
Dr Kpodonu: This is just for the GORE TAG device and not for the other devices, which include the Medtronic device, we have also used other devices like the EndoFit in the past. We have done most of these studies under investigational device exemption protocols but for this study we used only the FDA-approved Gore-TAG graft in the US.
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Footnotes
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Presented at the 21st Annual Meeting of the European Association for Cardio-thoracic Surgery, Geneva, Switzerland, September 16–19, 2007.
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References
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Abstract
1. Introduction
