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Tanaka et al. Vessel Plus 2023;7:28 https://dx.doi.org/10.20517/2574-1209.2023.108 Page 3 of 5

There is little doubt that TAAA patients with the four factors - sarcopenia, chronic obstructive pulmonary
disease, glomerular filtration rate < 60 mL/min, and age > 70 years - will likely have a higher incidence of
adverse outcomes, regardless of the open or endovascular approaches. However, the current meta-analysis
demonstrated that the endovascular group was prone to include patients with older age, chronic obstructive
pulmonary disease, coronary artery disease, and diabetes . Although current literature has yet to
[10]
demonstrate a definitive benefit of endovascular treatment in high-risk patients, these high-risk patients
would likely benefit more from endovascular repair, given the comparable outcomes between open and
endovascular treatment.

In the realm of endovascular treatment, there is a consideration for ensuring an adequate “landing zone” to
prevent endoleak, which may result in the treatment area being larger than the actual lesion extent. For
instance, a Crawford Extent 3 TAAA may necessitate coverage consistent with an Extent 2 classification.
When comparing the outcomes of open repair vs. endovascular treatment, there is ongoing debate as to
whether comparisons should be based on the extent of the lesion or the extent of the treatment. This
discussion is crucial, as it has significant implications for the evaluation of procedural efficacy and the
subsequent stratification of treatment outcomes. Further investigation is required to determine the most
appropriate metric for comparative analyses in this context.

CONNECTIVE TISSUE DISORDER
A recent review article on TAAA patients with connective tissue disorder (CTD) demonstrated that the
[11]
rates of early postoperative mortality after open and endovascular repairs were equivalent (8 studies with
458 patients on open repairs; 12 studies with 168 patients on endovascular repair). This is likely due to the
young age and minimal comorbidities in this patient population. However, the technical success rate with
endovascular repair varied from 38% to 100%, while that of open repair in all the studies was 100%. In
addition, stent-graft-related complications in this patient population were high: type I endoleak 8%-30%;
type II endoleak 17%-30%; and new dissection 17%.

Because of the young age presentation and fragile aortic wall with CTD, the durability of the repair remains
[11]
a concern, especially in the long term. In the previously mentioned review , the rate of reintervention in
the treated aortic segment with open TAAA was 4%-5% due to patch aneurysm. In addition, branch graft
patency is nearly 100%. On the contrary, reintervention to the treated aortic segment after endovascular
repair was observed in 8%-38%. In addition, in patients with CTD, false lumen may continue to have
persistent flow after the repair and cause growth, which was reported in 33%-38% of patients. Additionally,
open conversion ranged from 7%-50% in this review. Thus, TAAA patients with CTD should be considered
for open surgical repair due to both short-term and long-term benefits.

Two large series reported outcomes after open TAAA repair in patients younger than 50 years of age [12,13] . In
both series, incidence of CTD was 53%. Operative mortality is low in these young patients (3%-6%) with a
low reintervention rate (< 4% at 10 years in both series). As complex endovascular TAAA repairs have been
mostly used in older, high-risk patients, there is no study available to discuss the feasibility of endovascular
TAAA repair in the younger population.

In conclusion, younger TAAA patients with CTD should be considered for open surgical repair due to both
short-term and long-term benefits.