SIR: Stent-Graft Bests Surgery For Thoracic Aorta Repair

SEATTLE, March 5 -- Endovascular repair of thoracic aortic aneurysms may carry substantially less risk of paraplegia and other poor outcomes than surgery, British researchers said here.

Among 190 consecutive patients treated with stent grafts for diseased thoracic aortas, 3.8% had temporary or permanent paralysis whereas open surgery typically carries a 10% risk of paralysis, said John F. Reidy, M.D., of Guy's & St Thomas' Hospital in London, and colleagues.

The 8% mortality rate at 30 days also compared favorably with that for surgery, he said at the Society of Interventional Radiology meeting here.

The results support the shift from surgical to endovascular repair, Dr. Reidy said.

This represents a "seismic change" in medicine with complete replacement of an entire area of surgery that developed over hundreds of years, said Robert L. Vogelzang, M.D., of Northwestern Memorial Hospital in Chicago, who moderated a press conference at which the findings were discussed.

"The cumulative evidence for therapy of the descending aorta has now moved to a second tier, with endograft being first choice in every case where it can be done," he said, "and that's a huge change."

The prospective database study included all 127 men and 63 women (mean age 67) treated with nonsurgical thoracic aortic repair from 1997 to 2006 at a single center in England and followed for a mean of 20.4 months.

Most patients had degenerative aneurysm, though there were some dissections, ulcers, and other non-traumatic pathologies. The majority were elective procedures (128) while 62 cases were urgent repairs. Regional epidural anesthesia was used for 135. Nearly all (99.5%) of the stent-graft placements were successful.

The findings were:

• 8% 30-day overall mortality.
• 3.8% rate of paraplegia (seven of 190) though only two were permanent (about 1%).
• 3.8% rate of stroke.
• 8.9% late mortality.

Dr. Reidy said the mortality rate was "very acceptable." and the paralysis risk--"the most dreaded complication apart from death"--was likely better than that for surgery.

"We think that is better than surgery, but we don't have the randomized controlled data on that," he said.

Even with the early devices, when device failure was a concern, there was not thought to be equipoise between the two procedures, so no randomized controlled trials have been done other than for aortic dissection, he added.

Surgical repair requires the thoracic aorta to be clamped, which shuts off blood to the spinal column and thus increases risk of paralysis, whereas the endovascular procedure does not.

"Techniques and devices have evolved and continue to do so," Dr. Reidy noted.

"I think endovascular repair of thoracic aortic aneurysms is here and now and has significant advantages over surgery and is going to get better," he said.

He said longer term follow-up is needed, but there is no reason to think that the findings are not generalizable to the American patient population.