Endovascular Versus Open Repair of Intact Descending Thoracic Aortic Aneurysms

In the latest issue of JACC, the Stanford group led by Dr. Dake published a retrospective study to evaluate the effectiveness of thoracic endovascular aortic repair (TEVAR) compared to open surgical repair for descending aortic aneurysms.  
Among 4580 patients treated between 1999 and 2010,  1,235 patients with open surgical repair patients were matched to 2,470 undergoing TEVAR with follow-up through 2014. The primary endpoint was all-cause mortality, and the secondary endpoint was open or endovascular re-intervention on the descending thoracic aorta. At 180 days, mortality was higher in the surgical repair group (23.8% vs TEVAR 10.2%).  Despite a reduced risk for late death (hazard ratio, 0.86, P = 0.004) and reintervention (hazard ratio: 0.40, P < .001) in patients undergoing open surgical repair, the restricted mean survival time difference favored TEVAR, with a difference of -209.2 days (95% CI, -298.7 to -119.7 days; P < .001), revealing a substantial survival advantage with TEVAR at 9 years. The study concluded that open surgical repair was associated with increased risk of early postoperative mortality but reduced late hazard of death. Despite the late advantage of open repair, mean survival was superior for TEVAR. TEVAR should be considered the first line for repair of intact descending thoracic aortic aneurysms in Medicare beneficiaries.