Genetic disorders are a key factor in aortic aneurysms, especially in younger patients, encompassing well-defined syndromic conditions that increase the risk of acute aortic events and often necessitate invasive treatment at an earlier age.

Despite the high-risk nature of open repair in this population, clinical guidelines continue to recommend open repair as the primary choice over endovascular approaches, which are reserved for emergencies or as bridge procedures to definitive surgical repair.In this retrospective analysis, we assessed 992 patients who underwent open repair of type I thoracoabdominal aortic aneurysms from 1990 to 2022. Patients were stratified by the presence of HTAD (HTAD; n = 177, including 72 with Marfan syndrome) versus non-HTAD (n = 815). Binary logistic regression models were developed to identify predictors of operative death and adverse events. Median follow-up was 6.7 years.

At 10 years, both groups demonstrated similar repair failure rates (p = 0.4). However, the HTAD group showed significantly greater repair-free survival (p < 0.001) and lower mortality (p < 0.001). Furthermore, HTAD patients experienced markedly lower rates of operative mortality and adverse events but required more frequent reinterventions, particularly those with aortic dissection.

The authors emphasize the benefits of open repair for HTAD patients, given the low intraoperative mortality and subsequent adverse event rates, crucial in a younger patient group with long life expectancy. However, the increased likelihood of aortic reintervention, especially in those with dissection, remains an essential consideration.

COMMENTARY:
The advancement and growth of endovascular techniques have undoubtedly limited the role of open repair for distal aortic disease. However, in patients with aortic disease associated with genetic conditions, clinical guidelines continue to favor open repair.

This study provides a substantial sample of patients who underwent surgical repair of type I thoracoabdominal aneurysms, analyzing predictors of adverse events and operative mortality, with a particular focus on the HTAD group. This focus is noteworthy, given the young age of these patients and the frequent need for subsequent interventions. The study’s relevance lies in both the large sample size collected over three decades and the nearly seven years of follow-up for each patient, in addition to the specific patient population it examines.

Although the HTAD group had higher rates of aortic reintervention, as expected given their longer life expectancy, it is noteworthy that they also had extended repair-free intervals. Additionally, they achieved excellent outcomes in terms of operative mortality (1.7%) and adverse events (2.8%), which were significantly lower than in the non-HTAD group. The article’s authors conclude by noting that, although published series report a substantial risk of late reintervention in patients with chronic dissections managed endovascularly, even definitive open repair, despite achieving a lower proportion of reinterventions, remains challenging and is not without the need for future procedures.

No previous series have reported on type I aneurysm repairs in HTAD patients, making this study valuable in supporting what guidelines already recommend, with a IIaC evidence level, that open repair is the choice in an elective clinical setting. Thus, we conclude that open surgery in patients with type I thoracoabdominal aneurysms and heritable aortic disease continues to be the preferred approach over endovascular therapy.

REFERENCE:
Rebello KR, Green SY, Etheridge GM, Zhang Q, Glover VA, Zea-Vera R, et al. Outcomes After Extent I Thoracoabdominal Aortic Repair: Focus on Heritable Aortic Disease. Ann Thorac Surg. 1 de febrero de 2024;117(2):328-35.