Outcome comparison of thoracic endovascular aortic repair performed outside versus inside proximal landing zone length recommendation.

Abstract

Success of thoracic endovascular aortic repair (TEVAR) relies heavily on the proximal landing zone (PLZ) sealing. Most instructions for use of thoracic endografts recommend a PLZ length of at least 2 cm. Because of the complex aortic anatomic features, TEVAR landing in zone 1 to zone 3 may not meet this requirement. The aim of this study was to examine whether 2-cm PLZ nonadherence was related to adverse outcomes after TEVAR. A retrospective review was performed of patients who underwent zone 1, zone 2, and zone 3 landing TEVAR at a single institution between November 2013 and October 2018. Preoperative and postoperative computed tomography angiography images were analyzed using three-dimensional reconstruction. The patients were categorized into two groups: PLZ ≥2 cm (adherence group) and PLZ <2 cm (nonadherence group). Collected data included patient and anatomic characteristics. Primary outcomes were type IA endoleak, retrograde dissection, and graft migration. The cohort comprised 63 patients (18 in the adherence group and 45 in the nonadherence group) with a mean age of 53.3 ± 20.6 years. Indications for TEVAR were blunt thoracic aortic injury (65.1%), thoracic aneurysm (23.8%), penetrating ulcer (9.5%), and type B dissection (1.6%). Mean PLZ length was significantly shorter for the nonadherence group (8 ± 7 mm for the nonadherence group vs 34 ± 15 mm for the adherence group; P < .0001). PLZ location (2 zone 1, 15 zone 2, 46 zone 3) and oversizing (19.4% ± 8.3% for the adherence group; 20.3% ± 10.2% for the nonadherence group; P = .7) were similar between the groups. The mean PLZ aortic diameter of the adherence group was significantly larger than that of the nonadherence group (29 ± 5 mm for the adherence group; 25 ± 5 mm for the nonadherence group; P = .004). Mean follow-up time was 126.7 days (range, 0-644 days) for the adherence group and 233.8 days (range, 0-1750 days) for the nonadherence group (P = .2). During the study period, no primary outcome was observed in the adherence group, whereas 12 adverse events occurred in 10 patients in the nonadherence group (type IA endoleak, n = 10; graft migration, n = 1; retrograde dissection, n = 1). Of 10 type IA endoleaks, five were immediate (4 resolved spontaneously, 1 remained persistent) and five were delayed (1 resolved spontaneously, 1 remained persistent, 1 ruptured causing death, 2 required total arch replacement). Achieving recommended sealing zone of 2-cm centerline length is paramount to avoid device-related adverse outcomes. We recommend careful surveillance in patients undergoing urgent TEVAR with <2-cm PLZ.