Endovascular treatment outcomes for descending thoracic aortic pathologies in octogenarians: retrospective study

Introduction

In the past, elderly patients are not fit for open surgical treatment for thoracic aortic disease because of high morbi-mortality rate especially in the emergency setting compared with younger patients (1). Because of this issue, early diagnosis and minimally invasive treatment is the best option for these group to reduce surgical complications and poor outcomes. In 1992, thoracic endovascular aortic repair (TEVAR) was introduced and the first device of TEVAR was approved in the late 2005. Since then, TEVAR became the best option for treating penetrating atherosclerotic ulcers, traumatic transection, and acute, complicated, type B aortic dissection with high successful rate (2-4).

The mortality rate of TEVAR is dependent on age and timing. Patel et al. showed that TEVAR with shorter rate of hospitalization decrease the mortality rate compared with open repair of descending thoracic aortic aneurysm (DTAA) in patients older than 75 years old despite preoperative complex comorbidities (5). Risk of death after emergent TEVAR increased three to five times in patients older than 75 years of age compared to younger patients (5). Nevertheless, TEVAR in emergency life-threatening situations is considered the best treatment option in octogenarian patients with poor general health conditions.

Regarding the aging of the population, the indications for TEVAR in octogenarians are constantly increasing with little data on the results of this treatment in this population.

The aim of this study was to evaluate the short- and medium-term results of TEVAR for descending thoracic aorta diseases in octogenarians’ patients. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-973/rc).

Methods

Patients

A retrospective, observational analysis study was designed and conducted from a single institution (Timone Hospital, APHM) for all patients older than 80 years who underwent TEVAR between 2000 and 2021. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Timone Hospital, APHM (No. PADS24-347) and individual consent for this retrospective analysis was waived.

Data collection

The data were collected from the electronic medical records.

Anatomical results were analyzed using the latest available scanner during follow-up.

Risk factors

Risk factors including hypertension (HTA), diabetes, hypercholesterolemia, obesity, atrial fibrillation, respiratory failure, coronary artery disease (CAD), congestive heart failure (CHF), renal failure, connective tissue disease and family history of aortic disease were analyzed.

Technical success

The technical success was defined as the successful deployment of the stent graft, ensuring its appropriate positioning across the targeted segment of the thoracic aorta without open conversion and type I or III endoleak on the angiogram.

Indications for thoracic endovascular repair

The surgical indications for TEVAR were atherosclerotic aneurysm greater than 55 mm, complicated acute aortic dissection (persistent pain, malperfusion syndrome, and aortic rupture), aneurysmal evolution of subacute and chronic dissection greater than 55 mm and aortic rupture.

All cases were discussed in a multidisciplinary meeting composed of vascular surgeons, cardiac surgeons, interventional radiologists, cardiologists, and anesthesiologists.

Hybrid treatment with TEVAR and open supra-aortic debranching in at least two steps remains the first-line therapy at our aortic center when the lesion involves the arch, as previously described (6).

TEVAR

TEVAR was performed in a multimodal angiographic suite (Discovery IGS 730, GE Healthcare, Chicago, USA). Transesophageal ultrasound was systematically used to ensure correct positioning of the guide in the true lumen (TL) in aortic dissection.

Stent grafts were advanced and deployed using standard techniques. We used the following three stent grafts (W. L. GORE & Associates, Flagstaff, AZ, USA; Cook Medical Incorporated, Bloomington, IN, USA; Medtronic, Santa Rosa, CA, USA).

The decision to extend the proximal landing zone was based on the location of the primary entry tear (aortic arch or descending thoracic aorta).

The stent-graft size was determined by measuring the diameter of the proximal and distal landing zones on an orthogonal view of the total aorta using centerline reconstruction on computed tomography (CT). In case of aortic dissection, proximal and distal oversizing of 10% were performed and in case of degenerative aneurysm, proximal and distal oversizing of 20% were performed.

In elective patients, systematic revascularization of the left subclavian artery was performed to prevent the risk of spinal cord ischemia and cerebrospinal fluid drainage was performed when there was extensive coverage of the thoracic aorta with a stent graft (>250 mm) in the absence of contraindications.

Radiological analysis

All patients underwent a postoperative CT scan before discharge, at 3 and 6 months postoperatively and annually thereafter. Scan image analysis and measurements were performed by two independent vascular surgeons using three-dimensional (3D) imaging software (OsiriX software, Geneva, Switzerland). Diameter measurements were performed on the perpendicular axis according to the centerline using a semiautomated centerline algorithm preoperatively, and on the last available CT scan during follow-up. Aortic diameter regression was defined as a diminution in 5 mm and aortic diameter augmentation was defined as an evolution >5 mm.

Outcomes

The primary outcome was the perioperative morbi-mortality rate including cardiac and respiratory complications, stroke, transient ischemic attack, spinal cord ischemia, digestive complication such as bowel ischemia and renal complication.

The secondary outcomes were the technical success and anatomical results during follow-up.

Statistical analysis

Data are presented as the mean ± standard deviation (SD) for continuous variables and as counts (%) for categorical data. For categorical variables, the relationship between variables was studied using the Chi-squared test or Fisher’s exact test, as appropriate. The Mann-Whitney U test was used for continuous variables. The normality of the distribution of variables was assessed with the Shapiro-Wilk test. In addition to descriptive and univariate analyses, we conducted multivariate logistic regression to identify independent predictors of 30-day mortality and major postoperative complications. Variables with a P value <0.2 in univariate analysis were entered into the regression model. To avoid overfitting due to the small sample size, we included a maximum of four variables per model. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported. Statistical significance was set at P<0.05.

All statistical analyses were performed using IBM SPSS Statistics 20.0 (IBM, Inc., New York, USA).

Results

Demography

A total of 35 cases were included in this retrospective study. Among them, 20 (57.7%) were male and 23 (65.7%) had elective surgery. Eight cases (22.9%) received hybrid treatment. The commonest presentation was thoracic degenerative aortic aneurism in 26 cases (74.3%).

The most common cardiac risk factor was HTA [25 (71.4%)], followed by smoking [18 (51.4%)]. Gore tag graft was the most used graft [20 (57.1%)] (Table 1).

Technical success

Technical success was achieved in 100% of the procedures.

Perioperative mortality

The perioperative mortality was 14% (5/35) secondary to 4 pulmonary complications and 1 cardiac arrest due to aortic rupture with type I endoleak. Among the five patients (14%) who died within 30 days postoperatively, three deaths were related to pulmonary complications, including ventilator-associated pneumonia and acute respiratory failure. One patient died from retrograde aortic rupture caused by a type I endoleak at the proximal sealing zone, confirmed on postoperative CT angiography.

The mortality rate was similar between elective and emergent patients [16.7% (2/12) in emergency vs. 13.0% (3/23) electively, P=0.70]. There was no statistical difference between degenerative aneurysm and aortic dissection mortality [11.5% (3/26) vs. 22.2% (2/9), respectively P=0.80].

Mortality was not significantly related to the age and body mass index of the patients.

Perioperative morbidity

The perioperative morbidity was 42.9% (15/35) and the most common complication was respiratory complications in 20.0% of cases (7/35), P<0.01, including pneumonia, respiratory failure, and the need for prolonged mechanical ventilation. Cardiac complications were observed in 2.9% (1/35) of cases. This included myocardial infarctions, arrhythmias, and other cardiac events (Figure 1).

Figure 1 Distribution of all cases by specific post-operative complications.

Paraplegia occurred in 5.7% (2/35) of patients. Among these 2 cases, 1 patient was treated in emergency for complicated aortic dissection with malperfusion syndrome, paraplegia occurred at day 1 with complete recovery after cerebrospinal fluid drainage, and 1 patient for a degenerative distal thoracic aneurysm in elective condition with an extensive coverage (230 mm), the patient died at day 4.

Stroke was documented in an additional 5.7% (2/35) of cases.

Renal dysfunction was reported in 8.6% of the cohort, with 3 patients experiencing acute kidney injury or exacerbation of pre-existing renal disease.

Notably, 22.9% (8/35) of patients experienced minor complications such as groin hematoma and false aneurysm on the femoral or humeral arteries.

The statistical analysis showed that older age was significantly associated with the risk of post-operative major complications [82.6 (SD 3.5) vs. 84.9 (SD 3.8) years, P=0.01] and major complications was significantly associated with an increased risk of mortality (41.6% vs. 0%, P<0.01). Logistic regression analysis identified one independent predictors of 30-day morbidity: older age (OR 1.36; 95% CI: 1.007–1.85, P=0.044).

Endoleak

Type I endoleaks were observed in 8.6% (3/35) of the patient cohort. Among them, 2 occurred in aortic dissection, 1 patient died and 1 in degenerative aneurysm with favorable evolution after reintervention with proximal TEVAR. Hybrid treatment with supra-aortic trunk debranching was significantly associated with an increased risk of type I endoleak (66.7% vs. 9.4 %, P=0.04).

In additional 11.4% (4/35) of patients, type II endoleaks were observed.

Long term results

After a mean follow up of 24 months (SD 26.9 months), there were 5 perioperative deaths and 4 patients lost to follow-up, there were excluded for the long-term analysis.

Mortality

The rate of long-term mortality was 23.1% (6/26). The maximum aortic diameter was significantly greater in death patients [72.5 (SD 5) vs. 62.6 (SD 14.6) mm, P=0.02].

Anatomical results

Aortic diameter

The mean maximum aortic diameter of the studied cases was 69.74 (SD 19.9) mm (Figure 2A), and the mean aortic diameter in the last follow-up was 54.5 (SD 19.5) mm.

Figure 2 The regression of the aneurysmal sac. (A) The aneurysm prior to the 3-year follow-up; (B) the significant reduction in the size of the aneurysmal sac observed after 3 years of follow-up.

The maximal aortic diameter was stable in 18 cases (69.2%), in regression in 7 cases (26.9%) (Figure 2B) and in augmentation in 1 case (3.8%).

Discussion

Our study evaluated the outcomes of TEVAR for the management of thoracic aortic pathologies in a cohort of 35 octogenarian patients. The study population consisted predominantly of male patients (57.7%) who underwent elective procedures (65.7%), with the most common presenting pathology being thoracic degenerative aortic aneurysm (74.3%). We showed that TEVAR in this high-risk population is associated with a high rate of mortality at 14% without significant difference in emergency or elective patient.

Advanced age has been consistently linked to higher mortality rates and poorer perioperative outcomes in open repair of DTAA or thoracoabdominal aortic aneurysm (TAAA). Huynh et al. conducted a study involving 66 octogenarians who underwent open DTAA/TAAA repair, reporting a 30-day mortality rate of up to 50% in high-risk patients (defined as those presenting emergently, with a history of diabetes or CHF), and 17% in low-risk patients (7). In a more recent study by Di Luozzo et al., which included 93 octogenarian patients (mean age: 75 years), 15% of the patients died in the hospital, 3.2% experienced paraplegia, and 6.5% developed postoperative stroke (8).

The rapid advancements in endovascular technology offer elderly patients an opportunity for a less invasive and safer surgical intervention.

The European Collaborators of Stent/Graft Techniques for Thoracic Aortic Aneurysm and Dissection Repair, along with the United Kingdom Thoracic Endograft Registries, reported a combined 30-day mortality rate of 9.3% (9). These results are comparable to ours. Several studies have reported promising outcomes of TEVAR in octogenarians. For instance, Alnahhal et al. and Li et al. showed that with careful patient selection, TEVAR can offer acceptable early mortality and morbidity, particularly in elective settings. However, these studies also stressed the importance of anatomical suitability and the risk of stent-related complications such as type I endoleak, consistent with our findings. These insights underscore the need for individualized therapeutic planning in elderly patients (6,10).

In the same way, Ehrlich et al. conducted a comparative study on the outcomes of open surgery versus endovascular repair for DTAA, revealing a 30-day mortality rate of 30% in the surgery group compared to 10% in patients undergoing endovascular repair (11). While Greenberg et al. studied high-risk patients for endovascular repair based primarily on anatomical factors and found acceptable intermediate-term outcomes, subsequent studies have specifically evaluated the efficacy of TEVAR in older patients (12).

Older patients constitute a significant portion of individuals undergoing TEVAR for various acute and chronic conditions affecting the descending thoracic aorta.

TEVAR has emerged as the primary treatment modality for thoracic aortic repair.

The study conducted by Kpodonu et al. involved 44 octogenarians and was conducted at a single center. Similarly, Preventza et al. conducted their study at two high-volume centers and included 101 octogenarians. Another relevant study by Tim Buckenham et al. included 19 octogenarians. These studies are the most directly comparable to the current study, which included 35 octogenarians (13-15). In our study, older age was identified as a significant risk factor for the development of major postoperative complications, which is consistent with the known increased susceptibility of elderly patients to adverse outcomes following complex aortic interventions.

The technical success rate reported in the study by Kpodonu et al. and Preventza et al. was 100%, indicating that the procedures were successfully completed without any technical complications (13,14). In the study by Buckenham et al., the technical success rate was slightly lower at 84%. In our study, the technical success rate of the TEVAR procedures was excellent at 100%, demonstrating the technical proficiency of the surgical team (15). However, the perioperative mortality rate was 14%, with the mainly causes being pulmonary complications and aortic rupture with type I endoleak.

The incidence of permanent cerebral injury (stroke) and spinal cord injury in our study was 5.7%, which is consistent with the findings of Tim Buckenham et al. (15). In the study by Preventza et al., the stroke rate was 11%, with a 6% rate of permanent stroke. They also reported a 2% incidence of permanent spinal cord injury while in our study 5.7% (14).

Endoleak was another important finding, with type I endoleaks occurring in 8.6% of patients. Interestingly, the study found a significant association between hybrid treatment with supra-aortic trunk debranching and an increased risk of type I endoleak, which could be explain by more complex anatomy (aortic arch lesion) in these cases.

Numerous studies have shown promising outcomes of TEVAR in the treatment of DTAA and TAAA in octogenarians and septuagenarians (5,13,14,16). These studies have demonstrated that perioperative outcomes in octogenarians are comparable to those in non-octogenarians, with elective non-ruptured cases showing perioperative mortality rates ranging from 2% to 10%. However, for ruptured cases, octogenarians still face an increased risk of mortality and morbidity. In a study by Jonker et al., the 30-day mortality rate was 32.0% in patients older than 75 years compared to 13.4% in those younger than 75 years (P=0.04) (4). Interestingly in our study, the mortality rate was similar between elective and emergent patients, as well as between patients with degenerative aneurysms and aortic dissections.

In the present investigation, the long-term outcomes revealed a mortality rate of 23% during the mean follow-up of 24 months. Patients who died had significantly larger maximum aortic diameters compared to survivors, suggesting that aortic size may be a crucial prognostic factor in this patient population.

Regarding anatomical results, the study demonstrated durable long-term results, with the majority of patients (69.2%) showing stable aortic dimensions during follow-up.

Despite these challenges, the mortality and morbidity rates were still considered acceptable, indicating that TEVAR remains a worthwhile treatment option for thoracic diseases in elderly patients.

Limitations

This study has several limitations. First, the retrospective single-center design is subject to selection bias. Second, the small number of patients aged ≥80 years (n=35) limits the statistical power, particularly in subgroup and multivariate analyses. Third, the average follow-up period of 14 months may not fully capture mid- or long-term outcomes such as delayed endoleaks or aortic-related mortality. Finally, the lack of a younger comparator group limits age-based outcome interpretation. Future prospective multicentric studies with longer follow-up and broader populations are needed.

Conclusions

TEVAR in octogenarian patients is associated with higher morbidity and mortality than in the general population, regardless of the emergency and type of lesion treated. Careful evaluation of the patient’s comorbidities, anatomical criteria, and procedural urgency is essential. Our findings highlight that pulmonary complications and stent-related events remain relevant risks in this age group. A multidisciplinary approach should guide decision-making, and TEVAR should be considered on a case-by-case basis rather than as a systematic option in the elderly population.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-973/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-973/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-973/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-973/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Timone Hospital, APHM (No. PADS24-347) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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