Abstract Objective Little is known about the outcomes of aortic root operations that involve inducing hypothermic circulatory arrest (HCA) for relatively extensive proximal aortic surgery. We ...attempted to identify predictors of postoperative hospital length of stay (LOS) and factors that affect postoperative recovery. Methods During 2006-2014, 247/265 patients (93.2%) with disease extending into the aortic arch survived aortic root operations (206 elective, 41 urgent/emergent) in which HCA with moderate hypothermia was used. Stepwise multivariate regression analysis was performed to identify predictors of LOS (as a continuous variable) and prolonged LOS (defined as LOS >9 d, the median for the cohort). By this definition, 111 patients (45%) had prolonged LOS and 136 (55%) did not. Results Preoperative factors that independently predicted longer LOS in the entire cohort included age ( P= .0014), redo sternotomy ( P =.0047), and intraoperative packed red blood cell (PRBC) transfusion ( P =.0007). Redo sternotomy and intraoperative PRBC transfusion also predicted longer LOS in three subgroup analyses: one of elective cases, one from which total arch (TAR) procedures were excluded, and one limited to patients who were discharged home. Age predicted longer LOS in the non-TAR patients. Ventilator support >48 hours ( P <.0001) was associated with longer LOS. Elective valve-sparing root replacement (AVSRR) predicted a shorter LOS than valve replacement in multivariate regression analysis ( P =.028). Conclusions In patients undergoing aortic root surgery with HCA for disease extending into the aortic arch, reducing intraoperative PRBC transfusion except when absolutely necessary may reduce postoperative LOS and expedite recovery. Performing AVSRR, when feasible, may also reduce LOS.
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.
Aortic arch replacement remains among the most technically challenging cardiovascular operations, incurring considerable risk for perioperative death and stroke. The trifurcated graft technique, in ...which a double Y-graft is used to connect brachiocephalic branches to the main aortic graft, was recently developed to simplify arch reconstruction, reduce embolization, and minimize related cerebral ischemia. We examined early outcomes of aortic arch replacement performed by using single or double Y-graft variations of this technique.
Between December 2006 and May 2009, the Y-graft technique was used to perform aortic arch replacement in 55 patients. Thirty-three patients had prior median sternotomy (60%), and 34 (62%) had ascending aortic dissection. Axillary cannulation was used in 52 patients (95%), and hypothermic circulatory arrest and antegrade cerebral perfusion were used in all patients. Median systemic and cerebral circulatory arrest times were 65 minutes and 0 minutes, respectively. A first-stage elephant trunk repair was performed in 46 patients (84%). Follow-up data were obtained for all patients.
There were no in-hospital deaths and one 30-day death (2%). Three patients (5%) had strokes, 1 of which was transient. Actuarial 1-year and 2-year survival rates were 80.0% ± 5.4% and 77.6% ± 5.7%, respectively. Thirty-one of the elephant trunk patients (67%) subsequently underwent second-stage completion procedures, 5 (16%) of them endovascular.
Early results of aortic arch replacement by the Y-graft technique compare favorably with those of traditional approaches. The technique enables effective delivery of antegrade cerebral perfusion during complex arch procedures and incurs only a low risk of neurologic sequelae.
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.
Objective Endoluminal grafting is emerging as a less invasive alternative to the treatment of descending thoracic aorta diseases. Endoleaks (continued pressurization of the treated aorta external to ...the endoluminal graft) are a potential complication. We reviewed our cumulative endovascular experience for descending thoracic aorta pathologies with respect to the management of endoleaks and associated patient outcomes. Methods As part of a single-site investigational device–exemption protocol, 249 patients (146 men, 103 women) with thoracic aortic diseases underwent attempted delivery of a TAG endoprosthesis (W. L. Gore & Associates, Flagstaff, Ariz) between February 2000 and August 2005. Indications for study enrollment included 111 atherosclerotic aneurysms (44.6%), 67 aortic dissections (26.9%), 27 penetrating aortic ulcers (10.8%), 14 contained ruptures (5.6%), 11 pseudoaneurysms (4.4%), 9 acute aortic transections (3.6%), 7 aortobronchial fistulas (2.8%), 2 endoleaks (0.8%) after prior thoracic endoluminal grafting, and 1 (0.4%) adult coarctation. Endoleak surveillance was performed using serial computed tomography scans. Results Mean patient age was 68 years (range, 23-91 years). Endoleak developed in 38 patients (15.3%): 15 distal type I (39.5%), 13 proximal type I (34.2%), 8 type II (21.1%) and 2 type III (5.3%). No surgical intervention was performed in 26 patients (68.4%), in which the endoleak spontaneously resolved in 14 (53.8%), 8 (30.8%) are being monitored and are asymptomatic, 3 (11.5%) died of unrelated causes, 2 (7.7%) withdrew from the study, and 1 (3.8%) was lost to follow-up. Twelve patients (31.6%) required reintervention using an additional endoluminal graft: 8 (66.7%) with a proximal type I endoleak, 2 (16.7%) with a distal type I endoleak, 1 (8.3%) with both distal type I and type III endoleaks, and 1 (8.3%) with a type III endoleak. Open conversions were necessary secondary to device deployment difficulties in two patients (0.8%), and due to expansion of a thoracoabdominal aneurysm and rupture of an aneurysm secondary to a type II endoleak in one patient (0.5%) each. Conclusion Endoleaks are an infrequent, yet important, complication after thoracic endografting. Many endoleaks will resolve spontaneously, but some patients may require another endovascular intervention. Close surveillance is recommended for these patients; however, open conversion is rarely indicated. Because more diseases of the thoracic aorta are being treated using an endovascular approach, a standardized treatment algorithm is essential to safely and effectively manage associated endoleaks.
Abstract Objective Women fare worse than men after many cardiovascular operations, including CABG and valve surgery. We sought to determine whether sex affects outcomes after open thoracoabdominal ...aortic aneurysm repair. Methods We evaluated data on 3353 consecutive patients (1281 women, 38.2%) who underwent open thoracoabdominal aortic aneurysm repair between October 1986 and July 2015. We compared preoperative characteristics, surgical variables, and outcomes between men and women in the overall group. A propensity-matching analysis was performed to adjust for preoperative and intraoperative differences. A multivariable analysis was conducted to identify predictors of poor outcomes using relevant preoperative and intraoperative factors. Results Men had a significantly higher prevalence of comorbid conditions, including coronary artery disease, and presented more often with dissection; women were slightly older than men (median age, 69 62-74 years vs 67 57-73 years; p<.001) and more often symptomatic. Men underwent extent II and IV repairs more often, whereas women more often had extent I and extent III repairs. The propensity analysis resulted in 958 matched pairs. Overall, women and men had similar early mortality (7.9% vs 7.2%, p=.5) and adverse event rates (14.8% vs 14.1%, p=.6), which were similar in propensity-matched groups. Multivariable analysis showed that predictors of operative death and adverse event differed between the sexes. Survival and freedom from repair failure were similar between the overall and matched groups. Conclusions Men and women who undergo thoracoabdominal aortic aneurysm repair have similar outcomes, but there are important differences in several perioperative factors and predictors of poor outcomes.
Objective Although endovascular repair of the descending thoracic aorta has emerged as a viable treatment option, little is known about its potential to treat patients diagnosed with aortobronchial ...fistulas. We reviewed our comprehensive thoracic endografting experience with regard to the endovascular management and subsequent outcome of patients with aortobronchial fistulas to assess whether endoluminal graft repair is a realistic option. Methods Between February 2000 and November 2005, 255 patients were successfully treated with an endoluminal graft to the descending thoracic aorta. Indications for intervention included: atherosclerotic aneurysms (109/255, 42.7%), acute and chronic dissections (75/255, 29.4%), miscellaneous (34/255, 13.3%), penetrating aortic ulcers (30/255, 11.8%), and aortobronchial fistulas (7/255, 2.7%). Results Average patient age was 73.4 ± 10.1 years, with 4 male patients (4/7, 57.1%) and 3 female patients (3/7, 42.9%). All patients presented with hemoptysis, with 1 patient (1/7, 14.3%) requiring preoperative blood transfusion. Three patients (3/7, 42.9%) were diagnosed with atherosclerotic aneurysms, 3 patients (3/7, 42.9%) had pseudoaneurysms associated with prior open surgical repair, and 1 patient (1/7, 14.3%) had a prior endoluminal graft placed for a traumatic aortic transection. No standard postoperative antibiotic regimen was followed. There were no endoleaks, no incidences of paraplegia, and no endoluminal graft infections. Survival was 100% (7/7) at both 30 days and 1 year, and all patients are currently alive. Follow-up computed tomography was available for all 7 patients, with an average follow-up of 42.6 ± 28.5 months. Conclusions Endovascular management of aortobronchial fistulas appears to be safe and well tolerated, even in surgically high-risk patients, with minimal risk of prosthesis infection. Long-term surveillance and continued investigation are warranted.
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