The impact of angiotensin-modulating medications on outcomes of thoracic endovascular aortic repair in patients with thoracic aortic aneurysms.

Abstract

Withholding renin-angiotensin-aldosterone system antagonists before surgery has been suggested in previous studies on nonvascular procedures owing to their potential contribution to postoperative comorbidities. Evidence on the role of renin-angiotensin-aldosterone system modulation is limited in vascular surgery literature. This study investigates the impact of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) on outcomes of thoracic endovascular aortic repair (TEVAR) in patients with thoracic aortic aneurysms. The Vascular Quality Initiative database was queried for all patients who underwent TEVAR for thoracic aortic aneurysm between January 2014 and 2024. Patients aged <18 years and those with connective tissue disorders were excluded. Patients who required further open thoracotomy were also excluded from the analysis. Our primary outcomes were 30-day and 1-year mortality. Our secondary outcomes were postoperative myocardial infarction, dysrhythmia, number of packed red blood cell transfusions needed, same-day extubation, and prolonged length of hospital stay. Multivariate logistic regression analyzed short-term outcomes and Kaplan-Meier survival, and the log-rank test analyzed 1-year survival rates. Among 7839 eligible patients, those receiving preoperative ACEI/ARB were more likely to be male, non-Black, hypertensive, and diabetic and to have congestive heart failure, a history of coronary artery disease, some degree of kidney dysfunction, and better preoperative functional status. The 30-day and 1-year mortality rates were similar between groups (all P > .05). There were no significant differences in rates of postoperative myocardial infarction, packed red blood cell transfusion, or dysrhythmia. However, preoperative ACEI/ARB use was independently associated with higher odds of same-day extubation (OR, 1.38; 95% confidence interval, 1.07-1.77; P = .014) and a lower risk of prolonged hospital stay (OR, 0.88; 95% confidence interval, 0.80-0.97; P = .010). Despite several previous studies reporting adverse effects of preoperative ACEI/ARBs on surgical outcomes, this multi-institutional study found that patients receiving ACEI/ARBs preoperatively were more likely to be extubated on the day of the operation and had shorter hospital lengths of stay. There were no differences in other postoperative outcomes or survival up to 1 year. This study suggests continuing the use of ACEI/ARBs in patients undergoing TEVAR.