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.
We attempted to determine the true incidence of retrograde ascending aortic dissection (rAAD) and to challenge its reported association with distal aortic dissection or zone 0 deployment.
From ...January 2005 to August 2014, 305 patients who were at risk for rAAD underwent thoracic endovascular aortic repair. We excluded patients with prior ascending, hemiarch, or traditional or frozen elephant trunk grafts, or who required concomitant ascending graft placement. Patients in group A (n = 111, 36.4%) had distal aortic dissection or hematoma (n = 75, 67.6%) or required landing of the endograft in zone 0 of the native ascending aorta (n = 36, 32.4%). Patients in group B (n = 194, 63.6%) had nondissected descending or distal arch aneurysm (n = 172), penetrating ulcer (n = 9), coarctation (n = 6), endoleak not caused by dissection (n = 3), aortobronchial fistula (n = 3), or transection (n = 1).
The incidence of rAAD was 1.3% overall (n = 4), 0.9% in group A (n = 1, Cook Zenith TX2), and 1.5% in group B (n = 3; 1 Talent Captivia, 2 Cook Zenith TX2; p = 0.64). No zone 0-treated patient had rAAD. Two patients from group B died, and 1 was treated nonoperatively. The median interval between thoracic endovascular aortic repair and rAAD was 11 days (range, 0 to 90 days).
Post-thoracic endovascular aortic repair rAAD is a rare but lethal complication. Operator experience is crucial for prompt recognition and prevention. It does not appear that rAAD is specifically associated with distal aortic dissection or landing in zone 0. To our knowledge, this is one of the few studies to report the true incidence of rAAD in at-risk patients.
Abstract Objective We examined the early outcomes and the long-term survival associated with different degrees of hypothermia in patients who received antegrade cerebral perfusion (ACP) for ...>30 minutes. Methods During a 10-year period, 544 consecutive patients underwent proximal and total aortic arch surgery and received ACP for >30 minutes and 1 of 3 levels of hypothermia: deep (14.1°C-20°C; n = 116 21.3%), low-moderate (20.1°C-23.9°C; n = 262 48.2%), and high-moderate (24°C-28°C; n = 166 30.5%). A variable called “predicted temperature” was used in propensity-score analysis. Multivariate analysis was done to evaluate the effect of actual temperature on outcomes. Results The operative mortality rate was 12.5% (n = 68) overall and was 15.5%, 11.8%, and 11.5% in the deep, low-moderate, and high-moderate hypothermia patients, respectively ( P = .54). The persistent stroke rate was 6.6% overall and 12.2%, 4.6%, and 6.0% in these 3 groups, respectively ( P = .024 on univariate analysis). On multivariate analysis, actual temperature was not associated with mortality, but lower temperatures predicted persistent stroke and reoperation for bleeding. In the propensity-matched subgroups, the patients with predicted deep hypothermia had (nonsignificantly) greater rates of persistent stroke (12.2% vs 4.9%; relative risk, 1.08; 95% CI, 0.87-1.15) and reoperation for bleeding (14.6% vs 2.4%; relative risk, 1.14; 95% CI, 0.87-1.15) than the patients with predicted moderate hypothermia. On long-term follow-up (mean duration, 5.12 years), 4- and 8-year survival rates were 62.3% and 55.7% in the deep hypothermia group and 75.4% and 74.2% in the moderate hypothermia group ( P = .0015). Conclusions In proximal and arch operations involving ACP for >30 minutes, greater actual temperatures were associated with less stroke and reoperation for bleeding. There were no significant differences among the predicted hypothermia levels, although a trend toward a higher rate of adverse events was noticed in the deep hypothermia group. Long-term survival was better in the moderate hypothermia group.
Abstract Objective Excellent outcomes have been established for elective aortic root replacement (ARR). It is less clear whether extending the repair into the proximal aortic arch with hypothermic ...circulatory arrest increases risk. We examined the early outcomes of elective, primary ARR, with and without hemiarch replacement, in patients without previous cardiac surgery. Methods Over a 4-year period, 140 non-redo patients (median age, 54 years) underwent elective, primary ARR for root aneurysms; 119 patients (85%) had hemiarch replacement, and 21 (15%) had only ascending aortic replacement. Valve-sparing ARR was performed in 41 cases (29.3%) and valve-replacing ARR in 99 (70.7%). Moderate hypothermic circulatory arrest and antegrade cerebral perfusion were used in 118 (99%) hemiarch repairs. Results There were no operative deaths or permanent strokes. Complications included temporary renal dialysis (n = 1; 4.8%), transient neurologic deficit (n = 2; 9.5%), and tracheostomy (n = 2; 9.5%) after ascending aortic repair and bleeding requiring reoperation (n = 4; 3.4%), pericardial effusion requiring drainage (n = 9; 7.6%), and tracheostomy (n = 2; 1.7%) after hemiarch replacement. No stroke was observed in the hemiarch group ( P = .022; univariate analysis). The extent of the repair into the proximal arch did not appear to be associated with any adverse effect. Conclusions In non-redo patients, elective primary ARR has excellent early outcomes, regardless of whether repair extends into the proximal arch. Additional elective hemiarch replacement with moderate hypothermic circulatory arrest and antegrade cerebral perfusion has a low risk of neurologic complications and should be performed if necessary. Long-term data are needed to compare the rates of reintervention in the aortic arch in patients with or without proximal arch replacement.
More than one way to skin a cat Coselli, Joseph S., MD; Preventza, Ourania, MD
The Journal of thoracic and cardiovascular surgery,
06/2015, Volume:
149, Issue:
6
Journal Article
We evaluated the occurrence and treatment of aortic aneurysms in coarctation patients.
During 1962 to 2011, 943 cases of coarctation were repaired. Aortic aneurysms were identified in 55 patients ...(5.8%). Forty-eight had prior coarctation repair (median 23 years earlier, interquartile range 18 to 26 years). Forty-two aneurysms were found in the descending thoracic aorta (76.4%), 18 in the ascending aorta (32.7%), 8 in the left subclavian artery (14.5%), and 1 each (1.8%) in the abdominal aorta, iliac artery, and innominate artery. Twenty-three patients (41.8%) had multiple aneurysms. Twenty-five patients (45.4%) had a bicuspid aortic valve.
Fifty-three patients' aneurysms were treated surgically. Thirty-five (66.0%) had descending thoracic aortic repair, of whom 11 had aorto-left subclavian bypass. Aortic cross-clamping alone was used in 23 patients, left heart bypass in 4, and circulatory arrest in 8. Eleven patients underwent endovascular repair (20.8%). Proximal aortic aneurysms were repaired in 7 patients (13.2%); 1 had simultaneous antegrade endostent delivery. Four patients had ascending-to-descending aortic bypass (7.3%). Concomitant valve-sparing root repair was performed in 2 patients, Bentall in 4, aortic valve replacement in 3, and coronary artery bypass in 1. One 30-day death occurred (1.9%). Three patients (5.7%) had transient neurologic deficits, 2 (3.8%) required tracheostomy, and 11 (20.8%) had vocal cord paralysis.
Coarctation is a marker for aortic aneurysm formation in adults and merits long-term surveillance. Anatomic complexity and associated conditions can complicate the surgical repair. Various open, extra-anatomic, and endovascular techniques may be used.
Objectives To determine the preoperative and perioperative risk factors that significantly predict adverse outcomes after total arch replacement in patients with previous proximal aortic surgery and ...to analyze patient survival. Methods We performed univariate analysis and logistic regression on data extracted from a prospectively maintained database for 119 patients who had undergone total arch operations during a 7.5-year period. All patients had undergone previous proximal aortic surgery. The adverse outcome was defined as a single composite endpoint comprising operative mortality, permanent neurologic deficit, and renal failure necessitating permanent hemodialysis. Results The incidence of the composite endpoint was 13.5% (16 of 119 patients). The univariate predictors were preoperative pulmonary disease ( P = .010), cardiac ischemia time ( P = .032), and cardiopulmonary bypass (CPB) time ( P = .073). On multivariate analysis, the following were predictors of the composite endpoint: preoperative pulmonary disease ( P = .036), CPB time ( P = .039), concomitant coronary artery bypass ( P = .0057), previous aortic valve replacement ( P = .027), and previous thoracoabdominal aortic aneurysm surgery ( P = .057). Multivariate analysis showed that the CPB time predicted mortality ( P = .0044), and previous thoracoabdominal aortic aneurysm surgery predicted stroke ( P = .034). The overall survival was 85.3% during a median follow-up of 4.76 years (95% confidence interval, 4.2-5.1). Conclusions Aortic arch reoperations, although technically demanding, can produce acceptable results. Preoperative pulmonary disease, CPB time, and concomitant coronary artery bypass predicted an adverse outcome. The CPB time predicted mortality, and previous thoracoabdominal aortic surgery predicted stroke.
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.
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