Endovascular Aortic Repair Promising in Connective Tissue Disease

Pauline Anderson

June 16, 2023


Endovascular treatment of aortic pathology for patients with CTD has a high rate of early technical success, low 30-day mortality, and a midterm survival rate comparable with previous reports of open aortic surgery.


  • Current guidelines advise against endovascular aortic repair for patients with CTD other than in redo operations and as bridging procedures in emergencies. However, technical improvements have made endovascular aortic repair more feasible for patients with CTD and have extended treatment to those in whom open repair is either not possible, technically complex, or of high risk.

  • The EVICTUS study included 171 patients with CTD. Most (142) had Marfan syndrome (mean age, about 50 years; 63% men). Patients underwent endovascular repairs for aortic disease at 18 centers. About 89% were treated for aortic dissections; 11.1% were treated for degenerative aneurysms.

  • Emergent index procedure was the reason for endovascular approach in 18.7% of cases, a redo or secondary procedure in 53.2%, and contraindications for open surgery (such as a comorbidity or anatomical consideration) in 15.2%.

  • The estimated median follow-up time after the index procedure was 4.7 years.


  • Primary technical success (successful deployment of the device in the absence of surgical conversion to open repair, death in 24 hours or less, and type 1 or 3 endoleaks) at 30 days was achieved for 98.2% of patients, a result the authors deemed "excellent."

  • There were five deaths (2.9% of patients) during this 30-day period, all of which were aortic related.

  • Survival at 1 and 5 years was 96.2% and 80.6% for patients with Marfan syndrome, 93.8% and 85.2% for those with Loeys-Dietz syndrome, and 75.0% and 43.8% for those with vascular Ehlers-Danlos syndrome.

  • Patients often required secondary aortic procedures, but few (8%) needed conversion to open repair.


"Improvements in devices and techniques and ongoing follow-up may result in endovascular treatment for patients with CTD being included in guideline recommendations," the authors conclude.


The study was conducted by Karl Wilhelm Olsson, MD, PhD, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden, and colleagues. It was published online June 14 in JAMA Surgery. An accompanying editorial called the study "timely, relevant, and valuable."


The EVICTUS study was retrospective, and pathologies and procedures were heterogeneous. The study did not directly compare endovascular intervention with open aortic surgery, and it lacked long-term follow-up. Details of postoperative pharmacologic management were not included in the study protocol.


Olsson reported no disclosures; disclosures for co-authors can be found in the original article.

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