Effect of the Proximal Landing Zone Quality on TEVAR Outcomes—11-Year Real-World Experience with the Relay Stent Graft Family in Aortic Dissections

Abstract

Introduction:

The aim was to analyze long-term outcomes of thoracic endografts of the Relay group for treating aortic dissections (AD) with respect to the impact of proximal landing zone choice.

Methods:

The retrospective single-center study included all patients treated by thoracic endovascular aortic repair (TEVAR) for AD with at least 1 Relay endograft (Relay, RelayPlus, Relay non-bare spring (NBS), Relay NBS Plus; Terumo Aortic, Sunrise, Florida) between January 2008 and December 2019. Patients were grouped according to proximal endograft placement: group 1 (G1)—within healthy aorta and group 2 (G2)—outside healthy aorta. Computed tomography angiography (CTA) scans during follow-up (FU) were analyzed with regard to diameter changes of true/false aortic lumen, proximal/distal landing zone configuration, bird-beak configuration, endograft migration, and endoleaks. In addition, patient demographics, morbidity/mortality, and reinterventions during the early and late FU were analyzed.

Results:

In total, 64 patients (G1: n=23, 15 male, mean age 60±12 years; G2: n=41, 29 male, mean age 62±12 years) were included. In total, 50 patients (78%) had acute AD and 14 (22%) had chronic AD. In total, 48 (75%) of the procedures were urgent/emergent. In-hospital mortality was 6% (4/64), and estimated 1- and 6-year survival in G1 vs G2 was 78% (95% CI=0.94-0.63) vs 87% (95% CI=0.98-0.78) and 64% (95 CI=0.89-0.48) vs 80% (95% CI=0.99-0.64) without statistically significant difference G1 vs G2 (p_multivariate=0.25). Coronary artery disease (CAD) was a significant risk factor for survival (p=0.0005, HR=6.57 (2.23-18.95)). Peripheral ischemic complications were 7% (n=2) vs 13% (n=5) and 0% vs 5% (n=2) in G1 vs G2. Proximal aneurysm formation during FU and proximal stent graft movement >1.5 mm were found in 9% vs 21 and 52% vs 63% in G1 vs G2. There was a trend for better aortic remodeling in G1 (p_multivariate> 0.11).

Conclusion:

Proximal TEVAR landing in healthy aorta was associated with fewer peripheral ischemic complications, a lesser risk for stent graft movement >1.5 mm, a tendency for better aortic remodeling, and less proximal aneurysm formation during FU, even if survival differences were not significant. CAD was a major risk factor for long-term mortality and should therefore be taken into account preoperatively whenever possible.

Clinical Impact

The study results support proximal TEVAR landing in healthy aorta when treating aortic dissections(AD), showing fewer peripheral ischemic complications, a lesser risk for stent graft movement >1.5mm, a tendency for better aortic remodeling and less proximal aneurysm formation during long-term follow-up. The statistically non-significant trend for inferior long-term survival in patients with TEVAR landing in healthy aorta merits further investigation in contemporary cohorts. Finally, the results show that coronary artery disease is a major risk factor for long-term mortality after TEVAR for AD, highlighting the relevance of close monitoring and, whenever possible, preoperative cardiological patient work-up.