Management of hemothorax after thoracic endovascular aortic repair for ruptured aneurysms

Background: Thoracic aortic aneurysm rupture is often a fatal condition. Emergent thoracic endovascular aortic repair (TEVAR) has emerged as a suitable treatment option. Unfortunately, respiratory complications from hemothorax continue to be an important cause of morbidity and mortality even after successful management of the aortic rupture. We hypothesize that early hemothorax decompression after TEVAR for ruptured aneurysms decreases the rate of postoperative respiratory complications. Methods: Single-center, retrospective eight-year review of ruptured thoracic aneurysms treated with TEVAR. Results: Seventeen patients presented with ruptured degenerative thoracic aortic aneurysms, all of which were successfully treated emergently with TEVAR. The mean age was 74 years among the 12 (70.6%) men and 5 (29.4%) women treated. Inpatient and 30-day mortality rates for the entire cohort were both 17.6% (three patients). The 90-day mortality rate was 47.1% (eight patients). Thirty-day morbidities of the entire cohort included stroke (n = 1, 5.9%), spinal cord ischemia (n = 3, 17.6%; only one was temporary), cardiac arrest (n = 4, 23.5%; 3 were fatal), respiratory failure (n = 5, 29.4%), and renal failure (n = 5, 29.4%). A large hemothorax was identified in the majority of patients (n = 14, 82.4%). While six (42.9% of 14) patients had immediate chest tube decompression on the day of index procedure, three (21.4% of 14) patients had decompression on postoperative day 1, 4, and 7, respectively. Although not statistically significant, there were trends toward higher rates of respiratory failure (50.0% vs. 16.7%, P = 0.198) and 90-day mortality (62.5% vs. 33.3%, P = 0.280) for patients with delayed or no hemothorax decompression when compared to patients with immediate hemothorax decompression. Conclusions: The morbidity and mortality of ruptured degenerative thoracic aortic aneurysms remains high despite the introduction of TEVAR. In this single-center experience, there was a trend toward decreased respiratory complications and increased survival with early chest decompression of hemothorax after TEVAR.