Surgery vs Surveillance for Thoracic Aortic Aneurysm

(TITAN:SvS Trial)

Recruiting at20 trial locations

Overseen by Munir Boodhwani, MD

Age: 18+

Sex: Any

Travel: May Be Covered

Time Reimbursement: Varies

Trial Phase: Academic

Recruiting

Sponsor: Ottawa Heart Institute Research Corporation

Disqualifiers: Previous cardiac surgery, Connective tissue disease, Genetic aortopathies, Inflammatory arteritis, others

No Placebo Group

Approved in 3 Jurisdictions

Trial Summary

What is the purpose of this trial?

This trial compares early surgery to close monitoring for adults with a slightly enlarged main artery from the heart. The goal is to see which approach better prevents serious complications like tearing or rupture.

Will I have to stop taking my current medications?

The trial information does not specify whether you need to stop taking your current medications. It's best to discuss this with the trial team or your doctor.

What data supports the effectiveness of the treatment Thoracic Aortic Surgery, Thoracic Aortic Repair, Thoracic Endovascular Aortic Repair (TEVAR), Open Thoracic Aortic Surgery?

Research shows that thoracic endovascular aortic repair (TEVAR) is often preferred over open surgery because it generally leads to fewer complications and lower death rates for patients with thoracic aortic diseases. ^{1 2 3 4 5}

Is thoracic endovascular aortic repair (TEVAR) generally safe for humans?

TEVAR has been used for over a decade and is considered a standard treatment for thoracic aortic diseases. It is often preferred over open surgery because it tends to have lower risks of complications and death, although there can be late complications that sometimes require further surgery. ^{2 6 7 8 9}

How does thoracic aortic surgery differ from other treatments for thoracic aortic aneurysm?

Thoracic aortic surgery, including both open surgical repair and thoracic endovascular aortic repair (TEVAR), is unique because it directly addresses the aneurysm by either replacing the affected section of the aorta or reinforcing it with a stent. TEVAR is less invasive than open surgery, but it requires lifelong surveillance due to potential complications, whereas open surgery may have better long-term outcomes but involves a more invasive procedure. ^{3 10 11 12 13}

Research Team

Jehangir Appoo, MD

Principal Investigator

University of Calgary

Munir Boodhwani, MD

Principal Investigator

Ottawa Heart Institute Research Corporation

Eligibility Criteria

This trial is for adults aged 18-79 with an ascending aortic aneurysm measuring between 5.0 and 5.4 cm, who can provide informed consent and commit to follow-up. It excludes those unfit for surgery, with certain medical conditions or previous cardiac surgeries, pregnant women, or those with rapid aneurysm growth.

Inclusion Criteria

I am between 18 and 79 years old.

My aortic aneurysm is between 5.0cm and 5.4cm in size.

My aortic aneurysm is being monitored and will be eligible for the trial once it reaches 5.0 cm.

Exclusion Criteria

I am pregnant or planning to become pregnant.

I am unable to understand or sign the consent form.

You have a known connective tissue disease, such as Marfan syndrome, Loey-Dietz syndrome, or Turner syndrome.

Trial Timeline

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

1 visit (in-person)

Randomization and Pre-treatment

Patients are randomized to either the early surgery group or the surveillance group. Baseline assessments and pre-randomization evaluations are conducted.

10-12 weeks

1 visit (in-person)

Treatment/Surveillance

Patients in the surgery group undergo elective aortic surgery, while those in the surveillance group are monitored with CT scans and medical therapy.

2 years

Annual visits (in-person or virtual)

Follow-up

Participants are monitored for safety and effectiveness after treatment or surveillance, with assessments of mortality and acute aortic events.

2 years

Annual visits (in-person or virtual)

Treatment Details

Interventions

• Thoracic Aortic Surgery (Procedure)

Trial Overview The TITAN SvS trial randomly assigns patients to either early elective surgery to replace the enlarged part of the aorta or close monitoring (surveillance). The goal is to see which approach better reduces death and aortic tearing/rupture after two years.

Participant Groups

Group I: Surgery/Treatment Arm Experimental Treatment 1 Intervention

Patients in the Operative Registry will have thoracic aortic surgery

Group II: Surveillance Arm Active Control 1 Intervention

Patients in the Non-Operative Registry will be followed in clinic annually with a CT scan to monitor the status of their ascending aortic aneurysm, until the end of the study, the occurrence of an aortic event, or death.

Thoracic Aortic Surgery is already approved in Canada for the following indications:

Approved in Canada as Thoracic Aortic Surgery for:

• Thoracic aortic aneurysm
• Ascending aortic aneurysm
• Descending thoracic aortic aneurysm

Who Is Running the Clinical Trial?

Ottawa Heart Institute Research Corporation

Lead Sponsor

Trials

200

Recruited

95,800+

Dr. Thierry Mesana

Ottawa Heart Institute Research Corporation

Chief Medical Officer since 2014

MD from McGill University

Dr. Rob Beanlands

Ottawa Heart Institute Research Corporation

Chief Executive Officer since 2024

MD from the University of Ottawa

University of Calgary

Collaborator

Trials

827

Recruited

902,000+

Dr. Shweta Patel

University of Calgary

Chief Medical Officer since 2020

MD from the University of Baroda Medical College, India

Dr. Edward McCauley

University of Calgary

President and Vice-Chancellor since 2018

PhD in Ecology and Evolutionary Biology from the University of California, Santa Barbara

Findings from Research

In a study of 16 patients undergoing thoracic endovascular aortic repair (TEVAR), the procedure achieved a primary technical success rate of 93.75%, with complete exclusion of the aneurysm in 15 patients and no operative mortality.

Despite some complications, including four perioperative strokes (with three patients fully recovering), the intermediate-term outcomes were positive, suggesting that TEVAR could be safely extended to treat a wider range of thoracic aortic diseases.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Thoracic EndoVascular Stent Graft Repair for Aortic Aneurysm. Kim, JT., Yoon, YH., Lim, HK., et al.[2022]

In a study of 66 patients undergoing thoracic endovascular aortic repair (TEVAR), the procedure demonstrated acceptable mortality (10.61% at 30 days) and reintervention rates (21.21%), suggesting it is a feasible option for treating complex thoracic aortic diseases.

Underweight patients faced significantly higher risks of complications and endoleak compared to those with higher body mass index, indicating that body weight may influence postoperative outcomes in TEVAR.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The Clinical Impact of Thoracic Endovascular Aortic Repair in the Management of Thoracic Aortic Diseases. Molano, F., Rey Chaves, CE., Conde, D., et al.[2023]

In a study of 3,705 patients with intact descending thoracic aortic aneurysms, TEVAR (thoracic endovascular aortic repair) was associated with lower early postoperative mortality compared to open surgical repair, making it a safer initial treatment option.

While open surgical repair showed a lower risk of needing further interventions later on, TEVAR resulted in better overall survival rates at 9 years, suggesting it should be the preferred method for treating these aneurysms in Medicare beneficiaries.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Endovascular Versus Open Repair of Intact Descending Thoracic Aortic Aneurysms. Chiu, P., Goldstone, AB., Schaffer, JM., et al.[2020]

Thoracic endovascular aortic repair (TEVAR) significantly reduces early complications such as all-cause mortality at 30 days (odds ratio 0.44) and paraplegia (odds ratio 0.42) compared to open surgical repair, based on a meta-analysis of 42 studies involving 5,888 patients.

TEVAR also leads to fewer cardiac complications, transfusions, and shorter hospital stays, although there is no significant difference in long-term outcomes like stroke or mortality beyond one year.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease a systematic review and meta-analysis of comparative studies. Cheng, D., Martin, J., Shennib, H., et al.[2018]

In a study of 759 patients over 50 years old undergoing repair for descending thoracic aortic aneurysms, operative mortality rates were similar for both thoracic endovascular aortic repair (TEVAR) and open surgery, at 6.5% and 7.6% respectively.

However, TEVAR was associated with a significantly worse 5-year survival rate (54.2% compared to 65.6% for open repair) and a higher rate of aortic-related reinterventions (23.1% vs. 14.3%), suggesting potential long-term complications and the need for further procedures.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Outcomes after endovascular or open repair for degenerative descending thoracic aortic aneurysm using linked hospital data. von Allmen, RS., Anjum, A., Powell, JT.[2014]

TEVAR is a safe and effective treatment for thoracic aorta diseases, showing excellent long-term survival rates, especially in patients with traumatic aortic injury, where no late deaths occurred.

Long-term survival rates vary based on the type of aortic pathology, with patients who had previous type-A dissection treatment showing the lowest survival rate (50% at 5 years), while those with aneurysmatic aortic disease had a 55% survival rate at 5 years.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Long-Term Outcomes and Risk Factors Analysis for Patients Undergoing Thoracic Endovascular Aorta Repair (TEVAR), According to the Aortic Pathologies. Gallo, M., van den Berg, JC., Torre, T., et al.[2023]

Thoracic endovascular aortic repair (TEVAR) has shown reduced early morbidity and mortality rates compared to traditional open surgical repair for various thoracic aortic diseases, based on multiple case-series studies and reviews.

However, there is insufficient high-quality clinical data to demonstrate an improvement in long-term overall survival for patients undergoing TEVAR, highlighting the need for more rigorous randomized-controlled trials.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Thoracic endovascular aortic repair--indications and evidence. Cao, CQ., Bannon, PG., Shee, R., et al.[2022]

In a study of 50 patients who underwent open repair after thoracic endovascular aortic repair (TEVAR), the most common reasons for the subsequent surgery included type 1 endoleaks and retrograde aortic dissection, indicating that these complications can arise from TEVAR.

The open repair procedures were performed safely, with a low hospital mortality rate of 6% and no strokes reported, suggesting that while these surgeries are complex, they can lead to good early outcomes for patients.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Open aortic repair after prior thoracic endovascular aortic repair. Roselli, EE., Abdel-Halim, M., Johnston, DR., et al.[2014]

In a study of 72 patients undergoing thoracic endovascular aortic repair (TEVAR) over 13 years, the procedure showed promising survival rates with 93% at one month, 88% at one year, and 63% at five years, indicating its efficacy for treating thoracic aorta disorders.

The study reported a low complication rate, with only 7% of patients experiencing mortality within 30 days, primarily due to vascular issues, and emphasized the importance of considering revascularization of the left subclavian artery to prevent complications like subclavian steal syndrome.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

A Review of the Endovascular Management of Thoracic Aortic Pathology. Bell, D., Bassin, L., Neale, M., et al.[2015]

In a study of 8967 patients undergoing elective repair of thoracic aortic aneurysms, endovascular repair (TEVAR) was associated with a 46% lower risk of death compared to open repair, highlighting its safety and efficacy.

Patients who underwent TEVAR also experienced significantly fewer postoperative complications, including neurologic (48% lower odds), cardiac (76% lower odds), and respiratory complications (62% lower odds), making it a preferable option for surgical intervention.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Open versus endovascular repair of thoracic aortic aneurysms: a Nationwide Inpatient Sample study. Hughes, K., Guerrier, J., Obirieze, A., et al.[2014]

Thoracic endovascular aortic repair (TEVAR) is increasingly used for treating thoracic aortic conditions, especially in younger patients who will require long-term postoperative monitoring.

There is ongoing debate about the best methods and frequency of surveillance after TEVAR due to challenges like the inaccessibility of the thoracic aorta for ultrasound, risks of radiation exposure, and complications from contrast use in imaging.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The role of mandatory lifelong annual surveillance after thoracic endovascular repair. Wong, S., Mastracci, TM., Katsargyris, A., et al.[2012]

TEVAR (thoracic endovascular aortic repair) shows significantly lower early mortality and fewer complications like stroke and renal failure compared to open surgical repair (OSR) for thoracic aortic aneurysms, based on a systematic review of 15 studies.

However, OSR has a lower rate of re-intervention in the mid-to-long term, and long-term survival outcomes are inconsistent, indicating that the choice between TEVAR and OSR should consider individual patient factors and preferences.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Effectiveness of endovascular versus open surgical repair for thoracic aortic aneurysm: a systematic review and meta-analysis. Mahboub-Ahari, A., Sadeghi-Ghyassi, F., Heidari, F.[2022]

In a study of 150 patients undergoing either endovascular repair (TEVAR) or open surgical repair (OSR) for thoracic aortic aneurysms, TEVAR was found to have lower total costs from admission to discharge (£34,020) compared to OSR (£45,875), despite higher initial procedure costs due to device expenses.

While TEVAR had lower postoperative costs and shorter hospital stays, its follow-up costs over 12 months were slightly higher (£5,206) compared to OSR (£5,039), mainly due to hospital readmissions.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Costs of endovascular and open repair of thoracic aortic aneurysms. Gray, J., McCarthy, A., Samarakoon, D., et al.[2023]

References

1. Korea (South) pubmed.ncbi.nlm.nih.gov

Thoracic EndoVascular Stent Graft Repair for Aortic Aneurysm. [2022]

2. United States pubmed.ncbi.nlm.nih.gov

The Clinical Impact of Thoracic Endovascular Aortic Repair in the Management of Thoracic Aortic Diseases. [2023]

3. United States pubmed.ncbi.nlm.nih.gov

Endovascular Versus Open Repair of Intact Descending Thoracic Aortic Aneurysms. [2020]

4. United States pubmed.ncbi.nlm.nih.gov

Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease a systematic review and meta-analysis of comparative studies. [2018]

5. England pubmed.ncbi.nlm.nih.gov

Outcomes after endovascular or open repair for degenerative descending thoracic aortic aneurysm using linked hospital data. [2014]

6. Netherlands pubmed.ncbi.nlm.nih.gov

Long-Term Outcomes and Risk Factors Analysis for Patients Undergoing Thoracic Endovascular Aorta Repair (TEVAR), According to the Aortic Pathologies. [2023]

7. Japan pubmed.ncbi.nlm.nih.gov

Thoracic endovascular aortic repair--indications and evidence. [2022]

8. Netherlands pubmed.ncbi.nlm.nih.gov

Open aortic repair after prior thoracic endovascular aortic repair. [2014]

9. Australia pubmed.ncbi.nlm.nih.gov

A Review of the Endovascular Management of Thoracic Aortic Pathology. [2015]

10. United States pubmed.ncbi.nlm.nih.gov

Open versus endovascular repair of thoracic aortic aneurysms: a Nationwide Inpatient Sample study. [2014]

11. United States pubmed.ncbi.nlm.nih.gov

The role of mandatory lifelong annual surveillance after thoracic endovascular repair. [2012]

12. Italy pubmed.ncbi.nlm.nih.gov

Effectiveness of endovascular versus open surgical repair for thoracic aortic aneurysm: a systematic review and meta-analysis. [2022]

13. England pubmed.ncbi.nlm.nih.gov

Costs of endovascular and open repair of thoracic aortic aneurysms. [2023]