Outcomes of 3309 thoracoabdominal aortic aneurysm repairs Coselli, Joseph S., MD; LeMaire, Scott A., MD; Preventza, Ourania, MD ...
The Journal of thoracic and cardiovascular surgery,
05/2016, Letnik:
151, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Abstract Objective Since the pioneering era of E. Stanley Crawford, our multimodal strategy for thoracoabdominal aortic aneurysm repair has evolved. We describe our approximately 3-decade ...single-practice experience regarding 3309 thoracoabdominal aortic aneurysm repairs and identify predictors of early death and other adverse postoperative outcomes. Methods We analyzed retrospective (1986-2006) and prospective data (2006-2014) obtained from patients (2043 male; median age, 67 59-73 years) who underwent 914 Crawford extent I, 1066 extent II, 660 extent III, and 669 extent IV thoracoabdominal aortic aneurysm repairs, of which 723 (21.8%) were urgent or emergency. Repairs were performed to treat degenerative aneurysm (64.2%) or aortic dissection (35.8%). The outcomes examined included operative death (ie, 30-day or in-hospital death) and permanent stroke, paraplegia, paraparesis, and renal failure necessitating dialysis, as well as adverse event, a composite of these outcomes. Results There were 249 operative deaths (7.5%). Permanent paraplegia and paraparesis occurred after 97 (2.9%) and 81 (2.4%) repairs, respectively. Of 189 patients (5.7%) with permanent renal failure, 107 died in the hospital. Permanent stroke was relatively uncommon (n = 74; 2.2%). The rate of the composite adverse event (n = 478; 14.4%) was highest after extent II repair (n = 203; 19.0%) and lowest after extent IV repair (n = 67; 10.2%; P < .0001). Estimated postoperative survival was 83.5% ± 0.7% at 1 year, 63.6% ± 0.9% at 5 years, 36.8% ± 1.0% at 10 years, and 18.3% ± 0.9% at 15 years. Conclusions Repairing thoracoabdominal aortic aneurysms poses substantial risks, particularly when the entire thoracoabdominal aorta (extent II) is replaced. Nonetheless, our data suggest that thoracoabdominal aortic aneurysm repair, when performed at an experienced center, can produce respectable outcomes.
Background Recent technologic advances in endovascular devices have led to alternative approaches to thoracoabdominal aortic aneurysm (TAAA) repair; these innovative approaches must be compared with ...the “gold standard” of conventional open TAAA repair. To facilitate such comparisons, we evaluated contemporary outcomes of open TAAA repair. Study Design We retrospectively reviewed and analyzed data collected prospectively between May 2006 and October 2010 regarding 509 consecutive patients who underwent TAAA repair. Standard univariate statistical comparisons were performed, as well as multivariable modeling, to identify predictors of survival. Results A total of 305 patients (59.9%) had degenerative aneurysms without dissection, and 204 (40.1%) had aortic dissection. There were 104 (20.4%) urgent or emergent repairs and 26 (5.1%) ruptured aneurysms. Operative adjuncts were used selectively. Of the 290 patients (57.0%) who underwent extensive repairs (Crawford extents I and II), 282 (97.2%) had cerebrospinal fluid drainage, 257 (88.6%) had left heart bypass, and 213 (73.4%) had intercostal/lumbar artery reattachment. The overall operative survival rate was 92.1% (469 of 509), and survival was better after elective repairs (93.8% 380 of 405) than after urgent or emergent operations (85.6% 89 of 104, p = 0.005). Renal failure necessitating hemodialysis at discharge developed in 30 patients (5.9%). Permanent paraplegia occurred in 13 patients (2.6%). Actuarial survival was 79.1% ± 2.0% at 2 years. Conclusions Contemporary open TAAA repair is characterized by respectable early outcomes, particularly when repair is elective. Such results should be compared with those of evolving approaches, including endovascular and hybrid repairs.
Evolving endovascular approaches to thoracoabdominal aortic aneurysm (TAAA) repair are attractive alternatives to the "gold standard" of conventional open TAAA repair. However, open repair may be ...more suitable for younger patients. We compared the outcomes of open TAAA repair in younger (≤50 years) and older (>50 years) patients to evaluate operative risk in younger patients.
We analyzed retrospective and prospective data from 3,346 cases of open TAAA repair performed between 1986 and 2015. Of those patients, 445 (13.3%) were 50 years old or younger and 2,901 (86.7%) were older than 50 years at the time of repair. In the younger cohort, 237 patients (53.3%) had connective tissue disorder, and many (n = 359, 80.7%) had aortic dissection. Younger patients tended to be in good health, and rupture was uncommon (n = 11, 2.5%). The outcomes examined included adverse event, a composite endpoint that comprised operative death or persistent stroke, paraplegia, paraparesis, or renal failure requiring dialysis.
Comparisons between the two age groups showed that younger patients underwent more extent II repairs, urgent/emergent repairs, and visceral artery bypass procedures and had longer aortic clamp times. Nevertheless, younger patients had better early outcomes than did older patients, including lower rates of operative death (3.2% vs 8.2%, p = 0.002) and adverse events (5.2% vs 15.9%, p < 0.001). Multivariable analyses determined age 50 years old or younger to be an independent predictor of reduced adverse events (relative risk ratio = 0.29, p < 0.001).
Early outcomes of open TAAA repair were excellent for patients 50 years old or younger, despite the fact that these patients typically required extensive repairs.
In patients with Marfan syndrome (MFS), distal aortic dissection can necessitate thoracoabdominal aortic aneurysm (TAAA) repair in survivors of acute DeBakey type I dissection and those with DeBakey ...type III dissection. We examined outcomes of surgical repair of TAAA in patients with MFS with distal aortic dissection.
Data were analyzed for 127 consecutive TAAA repairs performed between January 2004 and June 2014 in patients with MFS and distal aortic dissection-DeBakey types I (n = 73) and III (n = 54). The median time from dissection onset to TAAA repair was 5.2 years (interquartile range IQR: 2.1 to 9.8 years) for the overall group and was longer in patients with DeBakey I (6.5 years, IQR: 3.5 to 13.9 years) than patients with DeBakey III (2.9 years, IQR: 0.6 to 6.0 years, p < 0.001). Eleven patients (9%) had acute or subacute dissection at the time of repair. Sixty-six patients (52%) underwent Crawford extent II TAAA repair. A composite end point, adverse event, was defined as operative death or permanent stroke, renal failure, paraplegia, or paraparesis.
Eight patients had adverse events (6%), including 5 operative deaths (4%). There was no permanent stroke and 1 case each of permanent paraplegia and paraparesis. At discharge, 2 early survivors (2%) had renal failure. Extent II repairs did not have substantially different outcomes from other repairs.
In these patients with MFS with aortic dissection, open TAAA repair incurred reasonable operative risk, but improvements are needed to reduce rates of renal failure. Extent II TAAA repair does not appear to increase operative risk in patients with MFS.
Pathologic conditions of the aorta remain a major source of morbidity and mortality for patients with Marfan syndrome (MFS). Extensive thoracoabdominal aortic aneurysm (TAAA) repair can prevent ...aortic catastrophe but carries substantial risk of perioperative adverse events. We evaluated midterm survival and quality of life (QoL) after contemporary Crawford extent II TAAA repair in patients with MFS.
From 2004 to 2010, 49 consecutive patients with MFS (mean age, 43.4 ± 12.0 years) underwent extent II TAAA repair (41 elective and 8 urgent/emergent procedures) with intercostal reimplantation. Thirty-six patients (73%) had aorta-related symptoms, and 45 (92%) had distal aortic dissection. Operative adjuncts included cerebrospinal fluid drainage (n = 47 96%), left heart bypass (n = 46 94%), and cold renal perfusion (n = 47 96%). Kaplan-Meier survival analysis was performed. QoL was assessed in 24 patients with a 12-item survey (12-Item Short Form Health Survey version 2 SF-12v2) a median of 5.3 (interquartile range IQR, 4.0-7.9) years postoperatively. QoL data were normalized and compared with data from the general population.
There were no operative deaths, strokes, paraparesis, or paraplegia. Two patients (4%) had permanent renal failure necessitating hemodialysis. The most frequent complication was vocal cord paralysis (n = 21 43%). Six-year Kaplan-Meier survival was 84% ± 6%. The 24 patients with QoL data had slightly worse physical component scores (46.0 ± 10.6) and slightly better mental component scores (51.4 ± 10.4) than the general population (50 ± 10 for both scores).
Operative treatment of extensive TAAA in patients with MFS enables excellent midterm survival and QoL. Cerebrospinal fluid drainage, left heart bypass, and cold renal perfusion probably aid in achieving excellent outcomes.
Objectives We sought to evaluate our contemporary outcomes with open thoracoabdominal aortic aneurysm (TAAA) repair in octogenarians to determine whether open TAAA repair is a viable option, with ...acceptable risk, in this elderly cohort. Methods We analyzed clinical data from 1267 enrolled patients who underwent open TAAA repair between 2003 and 2013. Eighty-eight patients (7%) were octogenarians (median age, 82 years; range, 80-92 years) and 1179 were 79 years of age or less. Results Aneurysm rupture was more common in octogenarians (14% vs 4.7%, P = .001), whereas aortic dissections predominated in younger patients (43.9% vs 13%, P < .001). Octogenarians had higher rates of visceral-branch endarterectomy/stenting (58% vs 33.5%, P < .001), adverse postoperative outcomes (36% vs 15.3%, P < .001), operative mortality (26% vs 6.9%, P < .001), and prolonged hospital stay ( P = .004). Among octogenarians, preoperative aortic dissection was most commonly associated with extent I repair (42% vs <10% for other extents, P < .001). Extent II repairs most frequently necessitated concomitant visceral-branch procedures and carried the highest risk of mortality (62%). Extent I and III repairs carried intermediate operative risk, and extent IV repairs posed the least risk (11%). Multivariate modeling analysis identified extent II TAAA ( P = .001; odds ratio, 11.6), presence of concomitant dissection ( P = .02; odds ratio, 5.6), and aneurysm rupture ( P = .02; odds ratio, 5.7) as independent predictors of operative mortality in octogenarians. Conclusions Open extent II TAAA repair carries significant risk for octogenarians; extent I, III, and IV repairs incur more reasonable postoperative risk. Although TAAA repair should not be denied to octogenarians based solely on age, extensive TAAA repair should be performed with caution.
Cardiac arrhythmias commonly arise after cardiac surgery and are associated with poor prognosis. In thoracoabdominal aortic aneurysm (TAAA) repair, these complications are poorly understood. We ...assessed characteristics, incidence, outcomes, and potential predictors of postoperative arrhythmia (PA) after open TAAA repair.
From 2010 to 2014, 403 consecutive open TAAA replacement operations were performed in patients without preoperative cardiac rhythm abnormalities at a single tertiary center. We compared preoperative characteristics, operative factors, and postoperative outcomes in patients with and without PA, and we used multivariable logistic regression to identify predictors of PA.
PA occurred after 107 (26.5%) procedures. Atrial fibrillation (23%) was the most common type of PA. Length of hospital stay and operative mortality were greater in patients with PA than in patients without it (p < 0.01 for both). Kaplan-Meier cumulative survival for patients with PA was lower than for patients without PA: 69.2% ± 4.6% versus 88.3% ± 2.0% at 1 year and 59.0% ± 5.3% versus 85.0% ± 2.3% at 3 years (p < 0.001 for both). The odds of PA increased with advancing age (1.07 per year; p < 0.001). In addition, the odds of developing PA were higher in patients who received visceral perfusion (odds ratio, 2.58; p = 0.001) and were lower in patients who underwent extent IV repair (odds ratio, 0.44; p = 0.01).
Postoperative cardiac arrhythmia was common after open TAAA repair. Older patients and patients who underwent visceral perfusion were more likely to develop PA. Cardiac arrhythmia after TAAA repair was associated with prolonged hospital stay, higher early mortality, and lower midterm survival.
Valve-sparing aortic root replacement (VSARR) is an alternative to traditional composite valve graft (CVG) root replacement. We examined early and midterm outcomes after VSARR.
A combined ...retrospective/prospective study was performed in 83 patients who underwent VSARR (16%) among 515 patients who underwent aortic root replacement during a nearly 12-year period. Thirty-six patients (43%) had a connective tissue disorder, 3 patients (4%) had acute aortic dissection, and 40 (48%) patients had at least moderate aortic regurgitation (AR). Twenty-eight patients (34%) had left ventricular hypertrophy or dilatation. The reimplantation VSARR technique was used in 82 patients (99%), and the Florida sleeve technique was used in 1 patient. Thirty-two patients (39%) underwent concomitant aortic arch replacement. For early survivors, the median duration of follow-up was 3.5 years (range, 5 days-12.2 years).
One patient had severe AR after VSARR that necessitated intraoperative conversion to a mechanical CVG. The 1 operative death and 1 stroke occurred in a patient with acute dissection. Actuarial survival was 96.4%±2.0% at 2 years and 86.9%±5.6% at 8 years. Six patients (7%) had late valve-related complications: 1 died of endocarditis, 4 underwent reoperation for severe AR and received replacement valves, and 1 had severe AR and is being monitored. Freedom from repair failure (reoperation, endocarditis, or severe AR) was 94.8%±2.6% at 2 years and 87.3%±5.7% at 8 years.
Valve-sparing aortic root replacement can have excellent early and respectable midterm outcomes, even when combined with arch repair. Further follow-up remains necessary to evaluate the long-term durability of VSARR.
We examined our contemporary experience with hemiarch and total arch replacement in patients with previous acute type I aortic dissection.
Over an 8.5-year period, 137 consecutive patients (median ...age 58 years, interquartile range, 50 to 67) underwent hemiarch or total transverse aortic arch replacement a median of 7.7 years (range, 67 days to 32 years; interquartile range, 2.8 to 12.3 years) after previous acute type I aortic dissection repair. Interventions involving only the aortic root, aortic valve, descending aorta, or thoracoabdominal aorta were excluded. Multivariate analysis of 20 potential preoperative and intraoperative risk factors was performed to examine early death, neurologic deficit, composite endpoint (operative death, permanent neurologic deficit, or hemodialysis at discharge), and long-term mortality.
Total arch replacement was performed in 103 patients (75.2%), hemiarch replacement in 34 (24.8%), and elephant trunk procedures in 77 (56.2%). Thirty-one repairs (22.6%) were emergent or urgent. There were 16 operative deaths (11.7%), 4 permanent strokes (3.6%), and 21 (15.3%) instances of the composite endpoint. In the multivariate analysis, congestive heart failure and cardiopulmonary bypass time independently predicted operative mortality (p = 0.0027, p = 0.018). Emergency operation approached significance for stroke (p = 0.088). Predictors of long-term mortality (during a median follow-up period of 5.1 years, 95% confidence interval: 4.4 to 5.8) were female sex (p = 0.0036), congestive heart failure (p = 0.0045), and circulatory arrest time (p = 0.0013); preoperative pulmonary disease approached significance (p = 0.074). Five-year survival was 73.2%.
In patients with previous acute type I aortic dissection repair, hemiarch and total arch operations have respectable morbidity and survival rates. Congestive heart failure predicts operative death, long-term mortality, and our adverse event endpoint. Cardiopulmonary bypass time predicts operative mortality, and female sex and circulatory arrest time predict long-term mortality.
Objectives In patients with acute DeBakey type I dissection, endovascular repair of the descending thoracic aorta during proximal aortic repair is an increasingly popular approach to preventing ...distal aortic sequelae and subsequent repair. To better define the risks and outcomes associated with these secondary operations, we examined our contemporary experience with open distal aortic repair in patients with chronic type I aortic dissection. Methods Data were collected between January 2005 and June 2013 regarding 198 consecutive open descending thoracic (n = 27) or thoracoabdominal (n = 171) aortic repairs performed in patients with chronic type I dissection. The median interval between the dissection onset and the subsequent distal operation was 5.0 years (interquartile range, 2.4-10.5 years). A total of 110 repairs (56%) were performed in patients with genetic disorders. Results There were 14 early deaths (7%). Permanent paraplegia developed in 2 patients (1%), 5 patients (3%) had permanent stroke, and 9 patients (5%) had permanent renal failure. Factors associated with early death included greater age ( P = .01), chronic obstructive pulmonary disease ( P = .01), clamping proximal to the left subclavian artery ( P = .004), and use of hypothermic circulatory arrest ( P = .002). The use of cold renal perfusion ( P < .001) was associated with early survival. Early death was not associated with genetic disorders, emergency surgery, or extent of aortic repair. There were 36 late deaths, yielding an actuarial 8-year survival of 65.6% ± 5.9%. At 7 years, freedom from repair failure was 95.7% ± 1.7%, and freedom from subsequent repair for disease progression was 84.8% ± 4.6%. Conclusions In survivors of DeBakey type I aortic dissection with distal aneurysm, open repair of the descending thoracic or thoracoabdominal aorta can be performed with excellent early survival, acceptable morbidity, and relatively few late aortic events.
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