Date of Award

2018

Degree Name

Master of Medicine / Surgery (Thesis)

Schools and Centres

Medicine

First Supervisor

Dr Raffi Qasabian

Second Supervisor

Dr Zelda Doyle

Abstract

Objectives: Thoracic aortic aneurysms (TAAs) affect 10 per 100,000 people, and are responsible for significant mortality. Open surgical repair carries substantial risks of both morbidity and mortality. Endovascular TAA repair is a relatively new technology, with numerous proposed benefits over open repair. However, data is yet to demonstrate whether endovascular TAA repairs outperform open repair. We sought to observe trends and outcomes of TAA repairs over the previous decade in order to identify the optimal method of management of thoracic and thoracoabdominal aneurysm repairs, as well as predictors of poor outcome.

Methods: We conducted a retrospective analysis of all patients presenting for management of thoracic and/or aortic (ruptured and non-ruptured) from 2003-2013, at two tertiary-level, acute care hospitals in Sydney, Australia.

Results: 179 patients presented with thoracic or thoracoabdominal aneurysms, 127 of whom were treated surgically, and five of whom presented with aneurysmal rupture. The 52 patients managed non-operatively were more likely to be older, and more likely to be female. Of the patients managed surgically, 69 had ascending aneurysms, 27 had arch aneurysms, and 31 descending TAAs. Thirty-one patients underwent repair of descending TAAs, 12 open and 19 endovascular. Patients undergoing endovascular repair of descending TAAs were significantly older than those undergoing open repair. Operative duration was significantly shorter for endovascular than open repair of arch and descending aneurysms.There were no differences in morbidity or mortality, duration of hospitalisation, or transfusion requirement between the groups.

Patients over 75 years of age with arch aneurysms were more likely to develop an endoleak or return to theatre than those under 75. Similarly, patients over 75 years undergoing descending aneurysm repair were twice as likely to have an endovascular repair, required more blood transfused, and have a longer ICU and total hospital stay. Otherwise, there were no predictors for poor outcome post-TAA repairs. There was a trend for increasing endovascular repair of descending aneurysms, but no change in morbidity or mortality over time.

Conclusion: Overall mortality was low during the study period, but morbidity after open or endovascular thoracic or thoracoabdominal aneurysm repair remains substantial. Apart from reducing surgical duration, endovascular repair demonstrated no additional benefits over open TAA repair. Patients over the age of seventy-five were more likely to suffer adverse events than those under seventy-five. However, the current study demonstrated that either open or endovascular TAA repair can be performed with low morbidity and mortality, even in elderly patients.

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