Demographics and clinical characteristics
A total of 34 patients, 22 with primary aortic and 12 with secondary aortic indications, underwent emergency TEVAR during the study period. In the primary aortic” (aneurysm, aortic dissection, PAU) and “secondary aortic” (iatrogenic, trauma and aortoesophageal fistula) groups, 72.7% and 83.3.6% were male, respectively (p=0.486). Mean age was 71.4 and 51.9 years (p=0.002) in the primary aortic and secondary aortic groups, respectively. Patients in the aortic group had higher prevalence of high blood pressure (77.2% vs 66.7%, p=0.003), diabetes mellitus (13.6% vs 0%, p=0.18), chronic heart disease (27.3% vs 16.7%, p=0.49), hyperlipidemia (13.6% vs 0%, p=0.18), renal insufficiency (27.3% vs 0%, p=0.046), and COPD (18.2 vs 0%, p=0.116). A summary of relevant demographics and comorbidities is presented in Table 1.
Etiology, classification, laboratory values and outcomes
In the primary aortic group, 64% had an aneurysm (Figure 1), 18% had an aortic dissection and 18% a PAU. In the secondary aortic group, 17% had an iatrogenic aortic lesion after spine surgery, 58% a trauma and 25% an aortoesophageal fistula (Figures 2 and 3). All patients underwent CT scan for diagnosis and after the surgery (Figure 4). Percutaneous access was performed in 31.8% of the patients in the primary aortic and 41.7% in the secondary aortic group (p=0.566). An operation in local anesthesia was performed in 31.8% of the patients in the primary aortic group and 25% in the secondary aortic group (p=0.677). Median duration of hospital stay was longer in the primary aortic group compared to the secondary aortic group (14.5 vs 8 days, p=0.746). Simultaneous surgery was similarly frequent in both groups (22.7% vs 25%, p=0.881). These included: hepatic artery bypass, aortic arch debranching, surgical treatment of a pelvic fracture, thoracotomy, bowel resection, trepanation, ECMO implantation and splenectomy.
Regarding the preoperative laboratory values, anemia and elevated lactate and creatinine levels were more frequent in the secondary aortic group when compared to the primary aortic group (Hb 6.36 (± 1.1) vs 6.62 (±1.1) mmol/l, p= 0.942, 92.1 (±43.6) vs 80.46 (±29.1) mmol/l, p=0.528, and 5.2 (±5.57) vs 1.35 (±0.21) umol/l, p=0.029). Regarding the postoperative laboratory values, anemia and elevated lactate and creatinine levels were also more frequent in the secondary aortic group when compared to the primary aortic group (Hb 5.93 (± 0.9) vs 5.65 (±0.071) mmol/l, p= 0.9, 97.2 (±47.8) vs 44.5 (±20.5), p=0.614, and 4.1 (±4.7) vs 1.15 (±1.43) umol/l, p=0.233).
Concerning in-hospital mortality, no statistically significant difference could be observed between the primary and secondary aortic groups (27.3% vs 33.3 %, p=0.711). No patient died after treatment for PAU or iatrogenic lesions. Mortality rates after TEVAR for aneurysm, dissection and traumatic lesions were 35.7%, 25% and 28.6%, respectively. Patients with aortoesophageal fistula had the highest mortality rate (66.7%). Morbidity (Dindo-Clavien grade >3) was not statistically significant different between the primary and secondary aortic groups (36.4% vs 33.3%, p=0.86). Morbidity included groin hematoma, thoracic bleeding, and multiple organ dysfunction. Two patients underwent a second TEVAR procedure for endoleak type I during the hospital stay. A summary is presented in table 2.
Independent factors associated with early death and postoperative morbidity
Preoperative hemoglobin level (p<0.001), postoperative creatinine level (p=0.009) and pre- and postoperative lactate levels (p<0.001) were found to be independent factors associated with postoperative mortality and morbidity (Dindo-Clavien >3). A summary is presented in table 3.