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Ann Thorac Surg 2004;77:81-86
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

Stent-graft repair of penetrating atherosclerotic ulcers in the descending thoracic aorta: mid-term results

Philippe Demers, MD, MSa, D. Craig Miller, MDa*, R. Scott Mitchell, MDa, Stephen T. Kee, MDa, Lynn Chagonjian, RNa, Michael D. Dake, MDa

a Department of Thoracic and Cardiovascular Surgery and Division of Cardiovascular and Interventional Radiology, Stanford University School of Medicine, Stanford, California, USA

Accepted for publication April 1, 2003.

* Address reprint requests to Dr Miller, Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305-5247, USA
e-mail: dcm{at}stanford.edu

BACKGROUND: Localized aortic pathoanatomic abnormalities are good targets for endovascular stent-grafting but only short-term results have been reported. Our objective was to determine the effectiveness of endovascular stent-graft treatment of patients with descending thoracic atherosclerotic penetrating atherosclerotic ulcers (PAU) and to identify risk factors for treatment failure.

METHODS: Between 1993 and 2000 endovascular repair of PAU with first-generation (custom-fabricated) and second-generation (commercial) stent-grafts was performed in 26 patients (mean age, 70 years), 6 (23%) of whom had rupture. Fourteen patients (54%) were not candidates for open surgical repair. Follow-up was 100% complete (average, 51 months; maximum, 114 months). Outcome variables considered in the multivariable analysis included death and treatment failure (composite end-point comprising early death, endoleak, stent-graft mechanical fault, late aortic event, reintervention, and aortic-related or sudden death).

RESULTS: Three patients (12% ± 7% [±70% confidence limits]) died within 30 days and 2 had an early type I endoleak. Primary success rate was 92%. Actuarial survival estimates at 1, 3, and 5 years were 85% ± 8%, 76% ± 8% and 70% ± 10% respectively and actuarial freedom from treatment failure was 81% ± 8%, 71% ± 9% and 65% ± 10%. Multivariable analyses identified previous cerebrovascular accident (hazard ratio [HR] 17.1, p = 0.02) and female sex (HR 7.4, p = 0.08) as independent risk factors for death. For treatment failure the predictors were increasing aortic diameter (HR 1.1 [per mm above the mean value], p = 0.01) and female sex (HR 5.5, p = 0.09).

CONCLUSIONS: Endovascular stent-graft repair is effective but not curative treatment for selected, high surgical risk, elderly patients with a descending aortic PAU over the medium term. Assiduous serial follow-up imaging after stent-grafting is mandatory to detect late complications especially in those with a large aorta.




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