Long-term Beta Blocker Use Lowers Postoperative Mortality While Initiating Beta Blockers Preoperatively Does Not Improve Outcomes in Thoracic Endovascular Aortic Repair.

Abstract

Objective: Beta-blockers play a pivotal role in reducing perioperative cardiac complications; however, their impact on outcomes following thoracic endovascular aortic repair remains unknown. Utilizing the Vascular Quality Initiative database, our study aims to uncover the impact and determine the optimal timeframe for initiating beta-blocker therapy prior to thoracic endovascular aortic repair.

Methods: A total of 4,724 thoracic endovascular aortic repair patients (2016-2023) were grouped as follows: non-beta-blocker users (NBB), beta-blocker initiators ≤30 days prior to procedure (I30), and long-term beta-blocker users for >30 days prior to procedure (L30). Primary outcomes were in-hospital death, stroke, myocardial infarction, and spinal cord ischemia. Secondary outcomes included pulmonary complications, cardiac complications, bowel ischemia, leg ischemia, and prolonged length of stay (≥2 days). A sub-analysis was conducted to assess the influence of beta-blocker use by thoracic endovascular aortic repair indication: Type B aortic dissection and thoracic aortic aneurysm. Multivariable logistic regression analysis was performed to control for confounding variables.

Results: We identified 1,480 NBB (31%), 778 I30 (16%), and 2,466 L30 (52%) patients. After adjusting for confounders, I30 patients showed no significant postoperative complication reduction compared to NBB. In contrast, L30 patients had reduced odds of perioperative death (aOR=0.62 [95% CI: 0.40-0.94]; p=0.025), pulmonary complications (aOR=0.60 [95% CI: 0.43-0.82]; p=0.002), and bowel ischemia (aOR=0.30 [95% CI: 0.12-0.73]; p=0.009), but had higher rates of spinal cord ischemia (aOR=1.99 [95% CI: 1.19-3.49]; p=0.038), compared to NBB. When stratified by indication, L30 Type B aortic dissection patients were associated with decreased risks of death (aOR=0.42 [95% CI: 0.18-0.97]; p=0.041), stroke (aOR=0.29 [95% CI: 0.09-0.92]; p=0.039), and pulmonary complications (aOR=0.30 [95% CI: 0.13-0.69]; p=0.004) compared to NBB. Among thoracic aortic aneurysm patients, L30 was associated with higher odds of spinal cord ischemia (aOR=3.09 [95% CI: 1.34-8.40]; p=0.014) compared with NBB, but no impact on stroke or death.

Conclusions: Long-term use of beta-blockers was associated with lower perioperative mortality but higher spinal cord ischemia following thoracic endovascular aortic repair. Type B aortic dissection patients had the additional benefit of lower stroke rates without increased spinal cord ischemia. In contrast, initiating beta-blockers preoperatively, independent of pathology, was not associated with improved outcomes. While further prospective studies are necessary, these results indicate that patients should continue their beta-blocker regimen before undergoing thoracic endovascular aortic repair, and appropriate management of spinal perfusion pressure should be ensured perioperatively.