The natural history of penetrating aortic ulcers (PAU) and intramural hematomas (IMH) of the aorta is not well described. While repair is warranted for rupture, unremitting chest pain or growth, there is no established threshold for treating incidental findings. Thoracic endovascular aortic repair (TEVAR) offers an attractive approach in treating these pathologies, however, peri-procedural and post-operative outcomes are not well defined.
Patients 18 or older identified in the VQI database who underwent TEVAR for PAU and/or IMH between 1/2011-2/2020 were included. We identified 1042 patients, of whom 809 had available follow-up data. Patient demographics and comorbidities were analyzed to identify risk factors for major adverse events (MAE), as well as postoperative and late mortality.
The cohort was 54.8% female and 69.9% former smokers with a mean age of 71.1 years. Comorbidities were prevalent with 57.8% classified ASA IV; 89.8% had hypertension, 28.3% chronic obstructive pulmonary disease (COPD), 17.9% coronary artery disease, and 12.2% congestive heart failure (CHF). Patients were predominately symptomatic (74%) and 44.5% underwent non-elective repair. MAE incidence was 17%. Independent predictors of MAE were history of CAD, non-Caucasian race, emergent procedural indication, ruptured presentation, and deployment of two or more endografts. In-hospital mortality was 4.3%. Seventy-three percent of index hospitalization mortalities were treatment-related. Of 809 patients with follow-up (mean 25.1 months±19 months), all-cause mortality was 10.6%. Predictors of late mortality in follow-up included age greater than 70 years, ruptured presentation, and history of COPD and ESRD. Subset analysis comparing symptomatic (74%) vs. asymptomatic (26%) patients demonstrated the former were frequently female (58.2% vs. 45.3%, p<.001) with a higher incidence of MAE (20.6% vs. 6.9%, p<.001), notably higher in-hospital reintervention rates (5.9% vs. 1.5%, p=.002) and mortality (5.6% vs. 0.7%, log-rank p=.015), and prolonged length of stay (6.9 vs. 3.7 days, p<.0001) despite similar procedural risks. In follow-up, late mortality was higher in the symptomatic cohort (12.2% vs. 6.5%, log-rank p=.025), with all treatment-related mortalities limited to the symptomatic group.
We demonstrate significantly higher morbidity and mortality in symptomatic patients undergoing repair compared to asymptomatic patients, despite similar baseline characteristics. Asymptomatic patients treated with TEVAR had no treatment-related mortality in follow-up, with overall prognosis largely dependent on pre-existing comorbidities. These findings, in conjunction with growing evidence highlighting the risk of disease progression and attendant morbidity associated with these aortic entities, suggest a need for natural history studies and definitive guidelines on the elective repair of IMH and PAU.

Copyright © 2020. Published by Elsevier Inc.