The primary objective of this study is to investigate
the effect of TEVAR on mortality, particularly in the
mid- and long-term. In our study, one-year survival
was 76.1%, two-year survival was 69%, and five-year
survival was 42.4%. In our study, mortality in the
emergency TEVAR procedure was 17.1 times higher
than in the elective TEVAR.
In a systematic review and meta-analysis on TEVAR
treatment in degenerative aneurysms, Biancari et al.[4]
found 30-day mortality to be 4% and one-year mortality
to be 19.7%. In a meta-analysis, 30-day mortality was
found to be 19% in patients who underwent TEVAR
with a ruptured TAA.[5] In our study, the 30-day
mortality was 2% (n=1) in patients who underwent
elective TEVAR, indicating a lower rate than reported
in the literature. This patient, who had exitus, died
from acute renal failure on the postoperative fifth
day. In a multi-center study, 30-day mortality was
found to be 27.9% in patients with a ruptured TAA
who underwent emergency TEVAR.[6] In our study,
the 30-day mortality was 27.3% (n=6/22) in patients
who underwent emergency TEVAR, consistent with
the literature data. The median time to death for our
patients who were taken to emergency TEVAR and
died was six (range, 0 to 10) days. We believe that,
in the cox regression analysis performed with five
parameters affecting 30-day mortality, emergency
TEVAR application increased the mortality by 17.1
times compared to elective TEVAR procedure. In
the aforementioned meta-analysis, the first 30-day
mortality in emergency patients who underwent open
surgery reached up to 33%.[5] In our study, although
there were patients with severe hypotensive shock in
the emergency TEVAR group, the mortality rate was
lower than the first 30-day open surgery mortality rate
reported in this meta-analysis. In our study, one-year
survival rate was 76.1%. In the cox regression analysis
of one-year survival; the emergency TEVAR procedure
increased the one-year mortality by 5.6 times. In
addition, unlike 30-day mortality, COPD increased
one-year mortality by 6.4 times and hyperlipidemia by
3.3 times. In our study, two-year survival rate was 69%
(45.5% of emergency patients and 79.6% of elective
patients). When the factors affecting two-year survival
were analyzed, COPD increased two-year mortality
by 6.2 times and emergency TEVAR by 3.9 times.
In a study conducted by Schaffer et al.,[7] 11,996
patients who underwent TEVAR for various reasons
were evaluated. The five-year survival rate was
calculated as 60% in patients treated with TEVAR.
In our study, the five-year survival rate was 42.4%.
When one-year and five-year causes of death were
examined in our study, none of the causes of death
were the aneurysms or events related to the TEVAR
procedure. While the most common cause of death at
one year was myocardial infarction, malignancy was
the most common cause of death at five years. In our study, since there was no aneurysm-related death in
the mid- and late periods; our five-year survival rate is
lower than the literature, suggesting that the causes of
comorbidities may be higher in patients included in the
study. When the factors affecting five-year mortality
were examined in our study, the most important
factors were advanced age and male sex. Other factors
were DM (increased mortality by 2.8 times) and
smoking (increased mortality by 3.1 times).
Another focus of the discussions in the literature
is whether sex has an effect on mortality. Deery et
al.[8] reported 12% mortality in female patients and
8% in male patients during one-year follow-up of
patients who underwent TEVAR. They found a
statistically significantly higher mortality rates among
female patients. In our study, there was no significant
difference in terms of 30-day mortality, and one- and
two-year mortality between male and female patients.
However, when the five-year mortality was examined
using the Cox regression analysis, male sex increased
the five-year mortality by 4.3 times compared to
female sex. Considering the causes of death of our
patients, the atherosclerotic process stands out which
may explain the higher frequency of mortality in men,
particularly in the long-term.
There are different findings in the literature when
other factors affecting mortality in patients treated
with TEVAR are examined. In a study conducted
by Geisbüsch et al.,[9] risk factors for mortality after
TEVAR were reported as renal failure, over 75 years
of age, and emergency operations as independent
risk factors. Chung et al.[10] defined the presence of
preoperative leukocytosis and aneurysm diameter as
independent risk factors for late mortality. Wang et
al.[11] reported the results of TEVAR in patients with
impaired renal function and that emergency patients
with a creatinine value of >2 mg/dL had a poor
prognosis. Dillavou and Makaroun[12] also reported
that increased preoperative creatinine levels had a
predictive value for mortality or morbidity endpoints.
Salihi et al.[13] showed that early mortality developed
due to low cardiac output syndrome. In a meta-analysis
by Harky et al.,[14] when the patients who underwent
TEVAR and those who underwent open surgery were
compared, the one-year mortality rate was 22.19%
and the five-year mortality rate was 44.26% in 3,908
patients who underwent TEVAR. In 10,672 patients
who underwent open surgery, the one-year mortality
rate was 24.04%, and the five-year mortality rate
was 37.37%. When these results were compared, no significant difference was found between one-year
and five-year mortality rates. In our study, one-year
mortality in patients who underwent TEVAR was
found to be 23.9%. The five-year survival rate was
found to be 42.4%. Considering five-year mortality
rates in our study versus the literature data, the deaths
at five years were not associated with an aneurysm.
We believe that TEVAR would not lose its advantage
in the mid- and long-term in the near future. The
secondary objective of our study was to evaluate midand
long-term complications of the TEVAR procedure.
In particular, the patients who required paresis, plegia,
endoleaks, and aneurysm-related reintervention after
discharge. In the meta-analysis by Biancari et al.,[4] the
rate of postoperative paraplegia was found to be 3.2%
and the rate of permanent paraplegia was found to be
1.4% in patients who received TEVAR due to TAA.
The formation rate of CVD was calculated 2.7%. In
our study, plegia/paresis occurred in seven patients
in the postoperative period (9.9%). In one of these
patients, plegia was permanent (1.40%). Three patients
developed CVD, and the rate of CVD occurrence was
calculated as 4.2%.
There are several limitations to this study. First,
since the tomography data of some postoperative
patients could not be accessed, these patients were
excluded from the study. Second, the postoperative
opaque nephropathy relationship could not be
established, as the data on how much opaque material
were used during the operation could not be reached in
most patients. Since it is a retrospective study, we could
not reach some patients such as tomography, blood
results, and postoperative follow-up and, therefore, we
had to reduce the number of patients in the study.
In conclusion, TEVAR treatment seems to show
similar results to open surgery in terms of mortality
and other complications in the mid- and long-term.
It seems that TEVAR treatment does not lose its
obvious advantage in the early period and, also, in the
mid- and long-term. With the developing stent-graft
technology, TEVAR results can be even better in the
future.
Declaration of conflicting interests
The authors declared no conflicts of interest with respect
to the authorship and/or publication of this article.
Funding
The authors received no financial support for the research
and/or authorship of this article.
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