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, Volume:
151, Issue:
5
Journal Article
Peer reviewed
Open access
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.
Abstract Objective We attempted to identify predictors of adverse outcomes after traditional open and hybrid zone 0 total aortic arch replacement. Methods We performed multivariable analysis using 16 ...variables to identify predictors of adverse outcomes (mortality, permanent neurologic events, and permanent renal failure necessitating hemodialysis) in 319 consecutive patients who underwent total aortic arch replacement in the past 8.5 years and a subgroup analysis in 25 propensity-matched pairs. A total of 274 patients (85.9%) had traditional open repair, and 45 patients (14.1%) had hybrid zone 0 total arch exclusion. Results Operative mortality was 10.3% (n = 33): 11.1% (n = 5) in the hybrid group and 10.2% (n = 28) in the traditional group ( P = .79). A total of 19 patients (5.9%) had permanent stroke (15 traditional 5.5% vs 4 hybrid 8.9%; P = .32), and 2 patients (both traditional) had permanent paraplegia ( P = 1.00). The hybrid group had more total neurologic events ( P = .051) but not more permanent strokes ( P = .32). Prior cardiac disease unrelated to the aorta ( P = .0033) and congestive heart failure ( P = .0053) independently predicted permanent adverse outcome (operative mortality, permanent neurologic event, or permanent renal failure). Concomitant coronary artery bypass grafting independently predicted permanent stroke ( P = .032), as did previous cerebrovascular disease ( P = .032). In multivariable analysis, procedure type (hybrid or traditional) was not an independent predictor of stroke ( P = .09). During a median follow-up of 4.5 years (95% confidence interval, 3.9-4.9), survival was 78.7%, with no intergroup difference ( P = .14). Conclusions Among contemporary cases, both traditional and hybrid total aortic arch replacement had acceptable results. Comparing these 2 different surgical treatment options is challenging, and an individualized approach offers the best results. Permanent adverse outcome was not significantly different between the 2 groups. Procedure type is not an independent predictor of permanent stroke. Prior cardiac disease, past or current smoking, and congestive heart failure predict adverse outcomes for total aortic arch replacement.
The purpose of our study was to examine when and how to implement the current endoluminal stent graft technology to treat ascending aortic disease.
During a 7-year period (March 2006 through July ...2013), 7 consecutive patients (median age, 69 years; range, 61.5 to 80.5 years) with multiple comorbidities underwent endoluminal repair of the ascending aorta. Six had an ascending aortic pseudoaneurysm, and 1 had iatrogenic coarctation. The median number of prior sternotomies was 2 (range, 1 to 4).
Technical success was achieved in all but 1 patient, with 1 death (14.3%) at 30 days. The endoluminal technology used included the Gore TAG (W.L. Gore and Associates, Flagstaff, AZ) thoracic graft (including the new C-TAG) in 6 patients, the Talent stent graft (Medtronic, Santa Rosa, CA) in 1, an Excluder cuff (W.L. Gore) in 2, and an Amplatzer occluder (AGA Medical Corp, Plymouth, MN) in 1. More than 1 stent was placed in 4 patients. Three patients required innominate artery stenting, and 1 required additional left common carotid artery stenting. One patient (14.3%) required intraoperative conversion to open surgical repair. Median follow-up was 14.4 months (interquartile 25th to 75th percentile range, 5.5 to 22.6 months) with 66.6% overall survival. No aortic-related death was reported during the follow-up period.
Stent grafting of the ascending aorta is feasible but limited and is reserved for high-risk individuals. Technical expertise is essential, and follow-up is mandatory. Technical points, tips, and challenges of the current endovascular technology to effectively treat the ascending aorta are described.
Objective Selective antegrade cerebral perfusion (ACP) during hypothermic circulatory arrest (HCA) provides cerebral protection during aortic arch surgery. However, the ideal temperature for HCA ...during ACP remains unknown. Clinical outcomes were compared in patients who underwent moderate (nasopharyngeal temperature, ≥20°C) versus deep (nasopharyngeal temperature, <20°C) HCA with ACP during aortic arch repair. Methods By using a prospectively maintained clinical database, we analyzed data from 221 consecutive patients who underwent aortic arch replacement with HCA and ACP between December 2006 and May 2009. Seventy-eight patients underwent deep hypothermia (mean lowest temperature, 16.8°C ± 1.7°C) and 143 patients underwent moderate hypothermia (mean, 22.9°C ± 1.4°C) before systemic circulatory arrest was initiated. Multivariate stepwise logistic and linear regressions were performed to determine whether depth of hypothermia independently predicted postoperative outcomes and blood-product use. Results Compared with moderate hypothermia, deep hypothermia was associated independently with a greater risk of in-hospital death (7.7% vs 0.7%; odds ratio OR, 9.3; 95% confidence interval CI, 1.1-81.6; P = .005) and 30-day all-cause mortality (9.0% vs 2.1%; OR, 4.7; 95% CI, 1.2-18.6; P = .02), and with longer cardiopulmonary bypass time (154 ± 62 vs 140 ± 46 min; P = .008). Deep hypothermia also was associated with a higher incidence of stroke, although this association was not statistically significant (7.6% vs 2.8%; P = .073; OR, 4.3; 95% CI, 0.9-12.5). No difference was seen in acute kidney injury, blood product transfusion, or need for surgical re-exploration. Conclusions Moderate hypothermia with ACP is associated with lower in-hospital and 30-day mortality, shorter cardiopulmonary bypass time, and fewer neurologic sequelae than deep hypothermia in patients who undergo aortic arch surgery with ACP.
Objective To evaluate the effectiveness of innominate artery cannulation in proximal aortic procedures, including those involving hypothermic circulatory arrest. Methods A total of 68 patients ...underwent innominate artery cannulation with a side graft during proximal aortic surgery performed by way of a median sternotomy. The indications for surgery were proximal arch aneurysm in 43 patients (63.2%), aortic dissection in 11 patients (16.2%), total arch aneurysm in 10 patients (14.7%), and ascending aortic aneurysm in 4 patients (5.9%). Six patients (8.8%) had undergone previous sternotomy. Hypothermic circulatory arrest with antegrade cerebral perfusion was used in 64 patients (94.1%). Of the 68 patients, 63 (92.6%) received antegrade cerebral perfusion to both cerebral hemispheres. The median antegrade cerebral perfusion time was 20 minutes (range, 15.0-33.0 minutes). Seven patients had periods of circulatory arrest without antegrade cerebral perfusion for a median of 20 minutes (range, 6-33 minutes). Results One patient died, for 30-day mortality of 1.5%. Three patients (4.4%) had strokes, two of whom had a partial recovery. Seven patients (10.3%) developed temporary postoperative confusion that resolved successfully in all cases. Conclusions Cannulating the innominate artery for arterial inflow is an alternative technique for proximal aortic surgery procedures. It is especially useful in cases requiring hypothermic circulatory arrest to deliver antegrade cerebral perfusion.
Antegrade cerebral perfusion (ACP) is standard treatment for complex aortic pathology and includes both unilateral (u-ACP) and bilateral (b-ACP) techniques. Focusing on proximal acute aortic ...dissection, we investigated the clinical effect of u-ACP versus b-ACP.
From January 2005 to May 2013, 157 consecutive patients presented with acute type A aortic dissection. Antegrade cerebral perfusion was used in 153 patients (97.4%). Ninety patients (58.8%) received u-ACP, and 63 (41.2%) received b-ACP. No retrograde cerebral perfusion was used. The target systemic hypothermia temperature during ACP was 22° to 24°C. The mean ACP, cardiopulmonary bypass, and cardiac ischemia times were 34.6 ± 18.0, 125.6 ± 48.0, and 92.6 ± 34.1 minutes, respectively.
The p values from logistic regression models indicated that in both groups combined, the ACP, cardiopulmonary bypass, and cardiac ischemia times predicted hospital mortality (p = 0.035, p = 0.0033, and p = 0.035, respectively) but not stroke. The operative mortality was 13.3% (n = 12) with u-ACP and 12.7% (n = 8) with b-ACP (p = 0.91). Of the survivors, 13 of 88 u-ACP patients (14.8%) and 8 of 62 b-ACP patients (12.9%) had a postoperative stroke (p = 0.75). A circulatory arrest time of >30 minutes was associated with stroke (p = 0.031). Temporary neurologic dysfunction was present in 10 u-ACP (11.4%) and 5 b-ACP (8.2%) patients (p = 0.53). Postoperative renal failure occurred in 10 u-ACP (11.4%) and 10 b-ACP patients (16.1%) (p = 0.40). Antegrade stent delivery in the descending thoracic aorta did not affect the ACP, cardiac ischemia, circulatory arrest, or cardiopulmonary bypass times.
As one of the largest single-center studies of the efficacy of u-ACP and b-ACP in patients with type A aortic dissection, operative mortality, stroke, temporary neurologic dysfunction, and renal failure rates were similar in both. In this intrinsically complex disease, survival is the most important outcome; u-ACP may provide cardiac surgeons with valuable technical simplicity during challenging procedures, and b-ACP may be justified for circulatory arrest times of more than 30 minutes.
In pregnancy, aortic tissue is the issue Preventza, Ourania, MD; Coselli, Joseph S., MD
The Journal of thoracic and cardiovascular surgery,
02/2017, Volume:
153, Issue:
2
Journal Article
Abstract Objective To evaluate adverse outcomes after elective aortic arch surgery performed at higher or lower temperatures (24.0°C-28.0°C vs 20.1°C-23.9°C) within the wide range of moderate ...hypothermia. Methods Over a 9-year period, a total of 665 patients underwent elective proximal (n = 479) or total (n = 186) arch replacement with moderate hypothermia and antegrade cerebral perfusion. Circulatory arrest was initiated at an actual temperature of 20.1°C to 23.9°C in the lower-temperature group (n = 334; 223 proximal, 111 total) and at 24.0°C to 28.0°C in the higher-temperature group (n = 331; 256 proximal, 75 total). Composite adverse outcome was defined as operative mortality or persistent neurologic event or persistent hemodialysis at discharge. Multivariate logistic regression analysis was used to model adverse outcome. In addition to the actual temperature, a new, balanced variable, “predicted temperature,” was analyzed to eliminate surgeon bias. We used this variable in a propensity score–matching analysis to validate the multivariate analysis results. Results A composite adverse outcome occurred in 7.2% of cases. Operative mortality was 5.1%. The rate of postoperative persistent neurologic deficits was 2.4%. No significant differences were found between the lower– and higher–predicted temperature groups within the moderate hypothermia range in the propensity score–matching analysis. The higher–actual temperature group had a lower rate of ventilator support at >48 hours ( P = .036) and less need for tracheostomy ( P = .023). Packed red blood cell transfusion and previous coronary artery bypass independently predicted composite adverse outcome ( P = .0053 and .0002, respectively), operative mortality ( P = .0051 and .0041), and postoperative stroke ( P = .045 and .048). Cardiopulmonary bypass time independently predicted composite outcome ( P = .0005), operative mortality ( P < .0001), ventilatory support for >48 hours ( P < .0001), and renal dysfunction ( P = .0005). Conclusions In elective proximal or total arch surgery, higher temperatures (≥24.0°C-28.0°C) within the wide range of moderate hypothermia (20.1°C-28°C) are safe and, compared with colder temperatures, not associated with significantly different rates of composite and adverse outcomes.
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