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Ann Thorac Surg 2000;69:409-414
© 2000 The Society of Thoracic Surgeons

Original Articles

Mortality and paraplegia after thoracoabdominal aortic aneurysm repair: a risk factor analysis

Joseph S. Coselli, MDa, Scott A. LeMaire, MDa, Charles C. Miller, III, PhDa, Zachary C. Schmittling, MDa, Cüneyt Köksoy, MDa, José Pagan, MDa, Patrick E. Curling, MDa

a Baylor College of Medicine, The Methodist Hospital, Houston, Texas, USA

Address reprint requests to Dr Coselli, 6560 Fannin, #1100, Houston, TX 77030
e-mail: jcoselli{at}bcm.tmc.edu

Presented at the Thirty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 25–27, 1999.


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
Background. Recent recommendations regarding thoracoabdominal aortic aneurysm (TAAA) management have emphasized individualized treatment based on balancing a patient’s calculated risk of rupture with their anticipated risk of postoperative death or paraplegia. The purpose of this study was to enhance this risk-benefit decision by providing contemporary results and determining which preoperative risk factors currently predict mortality and paraplegia after TAAA surgery.

Methods. Risk factor analyses based on data regarding 1,220 consecutive patients undergoing TAAA repair from 1986 through 1998 were performed using multiple logistic regression with step-wise model selection.

Results. The 30-day mortality rate was 4.8% (58 of 1,220) and the incidence of paraplegia was 4.6% (56 of 1,206). For elective cases, predictors of operative mortality included renal insufficiency (p = 0.0001), increasing age (p = 0.0005), symptomatic aneurysms (p = 0.0059), and extent II aneurysms (p = 0.0054). Extent II aneurysms (p = 0.0023) and diabetes (p = 0.0402) were predictors of paraplegia.

Conclusions. These risk models may assist in decisions regarding elective TAAA operations. For patients who are acceptable candidates, contemporary surgical management provides favorable results.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
"The more detailed consideration of various risk factors associated with rupture must be balanced against a similarly nuanced consideration of the risk of operation, including not only the risk of death but also of paraplegia."

— T. Juvonen and associates, 1997 J. Maxwell Chamberlain Memorial Paper [1]

The foundation for all patient management decisions involves determining whether the risk related to a disease’s natural history outweighs the risk of its treatment. In keeping with this tenet, Juvonen and associates [1] recently emphasized that the decision to proceed with thoracoabdominal aortic aneurysm (TAAA) repair must be based on each individual patient’s risk of rupture without operation versus their risk of death or paraplegia with operation. To facilitate the first half of this fundamental risk-versus-benefit analysis, the authors developed a predictive model that estimates a patient’s risk of rupture in 1 year if the aneurysm is not repaired. The other half of the assessment, however, requires the development of a separate model. The purpose of our analysis of contemporary results was to determine which preoperative risk factors currently predict early mortality and paraplegia after elective TAAA repair in order to enhance the risk-benefit decision-making process during management of individual patients.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
Patients
Between January 1986 and December 1998, 1,532 consecutive patients underwent graft repair of descending thoracic or TAAAs. Of these, 1,220 patients had TAAA repairs; the patients with aneurysms limited to the descending thoracic aorta are not considered further in this study. The patient characteristics at the time of TAAA repair are detailed in Table 1. There were 721 men (59.1%) and 499 women (40.9%). Patient ages ranged from 18 to 88 years (mean 65.7 years, median 68 years). Extensive TAAAs (Crawford extents I and II) were present in 65.1% of patients.


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  		Table 1. Preoperative Characteristics of 1,220 Patients Undergoing Thoracoabdominal Aortic Aneurysm Repair

 
Surgical technique
All operations were performed by the senior author (J.S.C.); the details of the surgical technique have been recently described elsewhere [2–4]. With regard to spinal cord protection, a combination of moderate heparinization, permissive mild hypothermia, sequential aortic clamping, and aggressive reattachment of critical intercostal arteries (T8 to L1) was used consistently throughout the entire series. Left heart bypass was used in 381 (31.2%) cases; no blood reservoir, heat exchanger, or oxygenator was incorporated in the bypass circuit. A detailed technical report describing our methods for using left heart bypass during TAAA repair was recently published [5]. Spinal evoked potentials were not monitored and cerebral spinal fluid drainage was not used routinely.

Study variables and definitions
All preoperative, intraoperative, and postoperative data were gathered prospectively over the 13-year period and entered into a database. In addition to patient age and gender, the preoperative characteristics analyzed are listed in Table 1. The aneurysms were classified based on extent as defined by Crawford and associates [6]. Aneurysms associated with aortic dissection were considered acute if surgery was performed within 14 days of the onset of pain; after 14 days, dissection was considered chronic. Patients were considered symptomatic when any symptom (acute or chronic, severe or mild) related to the aneurysm was present, including pain, hoarseness, dysphagia, etc. Patients with acute presentations were defined as those with acute pain, rupture, contained rupture, and complicated acute dissection [7]. Renal insufficiency was defined as serum creatinine exceeding 3.0 mg/dL or need for hemodialysis. All patients with a history of diabetes, regardless of the duration of disease or the current need for antidiabetic agents, were included in the diabetes category.

Operative mortality was defined as death occurring within 30 days or within the initial postoperative hospitalization [8]. All patients with postoperative neurologic deficits involving the lower extremities were included in the paraplegia category, regardless of whether the deficit was weakness (paraparesis) or paralysis, immediate or delayed, or transient or permanent. This included patients with unilateral lower extremity deficits, unless an associated deficit involving the ipsilateral upper extremity (indicating a stroke) was present. Renal failure was defined as an increase in serum creatinine to greater than 3.0 mg/dL (if normal preoperatively) or the need to initiate hemodialysis. Pulmonary complications were defined as ventilator support exceeding 48 hours, reintubation, adult respiratory distress syndrome, atelectasis requiring bronchoscopy, chylothorax, prolonged air leak, pleural effusion requiring drainage, pneumonia, or pneumothorax requiring evacuation.

Statistical analyses
The statistical analysis was performed using the SAS (release 6.10; SAS Institute, Inc, Cary, NC) and SPSS (release 6.1.3; SPSS, Inc, Chicago, IL) systems for Windows. Risk factors were evaluated for association with operative mortality or paraplegia using univariate analyses: categorical variables were analyzed using the {chi}2 or Fisher’s exact test and continuous data were analyzed using Student’s t test. Risk factors that emerged with significance levels below 0.25 were analyzed via multiple logistic regression with step-wise model selection. Associations with outcomes were considered statistically significant when p values less than 0.05. Actuarial survival was estimated using the Kaplan-Meier method.

In creating the model for predicting an individual patient’s risk of death or paraplegia, only factors relevant to the decision making process (ie, information available at the time of preoperative evaluation) were entered into the analysis. Furthermore, because almost all patients with acute presentations undergo emergency operation, the need for a detailed decision analysis is essentially limited to elective cases; the 112 patients with acute presentations, therefore, were excluded in this portion of the analysis.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
Overall operative morbidity and mortality
Four patients (0.3%) died in the operating room. The early operative mortality rate was 7.3% (89 patients), which included 58 30-day deaths (4.8%) and 87 in-hospital deaths (7.1%). The incidence of paraplegia was 4.6% (56 of 1,206; excludes the 10 patients with preoperative paraplegia and 4 patients who died during operation); of these 56 patients, 33 (58.9%) had paraparesis. Renal failure developed in 11.1% of patients (133 of 1,198; excludes 18 patients receiving preoperative hemodialysis and 4 patients who died during operation); 72 of these 133 patients (54.1%) required hemodialysis. Pulmonary complications occurred in 415 patients (34.1%). Twenty-seven patients (2.2%) required reoperation for postoperative bleeding. Stratified results based on aneurysm extent are listed in Table 2. Actuarial survival rates were 88.9% at 1 year, 87.8% at 2 years, 81.6% at 4 years, and 63.7% at 6 years (Fig 1).


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  		Table 2. Results of Thoracoabdominal Aortic Aneurysm Repair in 1,220 Consecutive Patients

 


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  		Fig 1. Kaplan-Meier curve demonstrating actuarial survival after TAAA repair in 1,220 consecutive patients.

 
Risk analysis for operative mortality after elective repair
This analysis of risk factors predictive of operative mortality in individual patients was based on preoperative variables in the 1,108 patients undergoing elective operation. In this group of patients, the operative mortality rate was 6.3% (70 patients). Univariate analysis revealed the following factors to be associated with operative death (Table 3): increasing age, extent II aneurysm, symptomatic aneurysms, renal arterial occlusive disease, renal insufficiency, and hemodialysis. Based on the significant risk factors determined by multivariable analysis (Table 4), the probability of a patient dying after TAAA repair is predicted by:

where odds = exp [(age x 0.0535) + (C2 x 0.7219) + (symptoms x 0.9051) + (renal x 1.1730) - 7.4964]; age = patient age in years, C2 = 1 for patients with an extent II aneurysm and 0 for patients with an extent I, III, or IV aneurysm; symptoms = 1 or 0, respectively, for patients with or without symptoms related to the aneurysm, and renal = 1 or 0, respectively, for patients with or without renal insufficiency.


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  		Table 3. Results (p Values) of Univariate Analyses Regarding Factors Associated With Operative Mortality and Paraplegia After Thoracoabdominal Aortic Aneurysm Repair

 

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  		Table 4. Results of Multivariable Analyses for the Patient Risk Models for Operative Mortality and Paraplegia

 
Risk analysis for paraplegia after elective repair
The incidence of paraplegia after elective TAAA repair was 3.6% (40/1,099; excludes intraoperative deaths and patients with preoperative paraplegia). Age and extent II TAAA were the only risk factors associated with paraplegia in the univariate analysis (Table 3). Extent IV aneurysms and prior thoracic aneurysm repair were associated with decreased risk. The results of the multivariable analysis are listed in Table 4. The probability of a patient developing paraplegia or paraparesis after TAAA repair is predicted by:

where odds = exp [(diabetes x 1.0327) + (C2 x 0.9932) - 3.7704], diabetes = 1 or 0, respectively, for patients with or without diabetes, and C2 = 1 for patients with an extent II TAAA and 0 for patients with an extent I, III, or IV TAAA.


   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
The recent analysis regarding the risk of rupture for patients with thoracic aortic aneurysms by Juvonen and associates [1] was the primary impetus for our analysis concerning elective cases. Unsatisfied with the usual method of assessing the risk of rupture ("big aneurysm vs small aneurysm" [Fig 2A]) the Mount Sinai group performed a multivariable analysis that included data from computer-generated three-dimensional computed tomographic reconstructions of the thoracoabdominal aorta. The resulting formula determines the probability of rupture within 1 year based on patient age, the presence of pain and chronic obstructive pulmonary disease, and the maximum true diameters of the descending thoracic and abdominal aortic segments (Fig 2B).



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  		Fig 2. Demonstration of the risk versus benefit balance that is central to decisions regarding elective surgical repair of thoracoabdominal aortic aneurysms. Estimation of the risk of rupture was previously based solely on aneurysm size (A). The recently developed Mount Sinai formula provides a means for calculating the probability of rupture (B). New predictive formulas were developed to estimate the risks of postoperative mortality and paraplegia based on contemporary results (C). Modified from Juvonen and associates [1].

 
The risk analysis of our series was undertaken to balance the Mount Sinai model for risk of rupture with a complementary model that predicts operative risk based on contemporary results (Fig 2C). Using the risk formulas presented above, the probabilities of early death and paraplegia (Table 5) after TAAA surgery can be directly calculated for an individual patient. Alternatively, risk stratification curves can be used to rapidly obtain an estimation of risk for any given patient (Fig 3) [1]. For example, using Figure 3 and Table 5, a 75-year-old nondiabetic patient with renal insufficiency and an asymptomatic extent II TAAA would have an 18% risk of operative death and a 5.9% risk of paraplegia. By comparing the calculated risks of death or paraplegia after operation with the calculated risk of rupture without surgery, decisions regarding treatment can be supported with objective data.


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  		Table 5. Predicted Risk for Postoperative Paraplegia After Thoracoabdominal Aortic Aneurysm Repair Based on the Presence of Diabetes and the Extent of Repair

 


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  		Fig 3. Risk stratification curves (based on particular combinations of risk factors) to allow rapid estimation of the risk for operative mortality after elective repair of TAAAs. The probability of operative mortality is determined using the first set of curves (A) for patients with extent II TAAAs and the second set (B) for patients with extent I, III, or IV aneurysms. For patients without renal insufficiency and without symptoms, the age curve is used. The subsequent curves are used for those patients with symptoms, renal insufficiency, or both risk factors, respectively.

 
Increasing age and preoperative renal insufficiency have remained major risk factors for early mortality throughout the history of TAAA repair. Both were among the predictive variables determined by Svensson and associates [9] in their multivariable analysis of Crawford’s complete experience with TAAA surgery in 1,509 patients treated between 1960 and 1991. The recent report by Acher and associates [10] confirms that, along with acute presentation, age and elevated creatinine levels remain important predictors of early death.

The presence of symptoms related to the aneurysm was also an important predictor of operative mortality. This occurred despite excluding all patients with acute presentations in the analysis, leaving only those patients who had chronic or mild symptoms that were not considered signs of impending rupture. Similarly, Juvonen and associates [1] documented an increased risk of rupture in patients who had pain that experienced surgeons had characterized as being unrelated to the aneurysm. Along the continuum between truly asymptomatic aneurysms and ruptured aneurysm, the appearance of even mild symptoms seems to represent progression into a subacute phase that carries both an increased risk of rupture and an increased perioperative mortality rate. Therefore, the development of any symptoms, no matter how mild or uncharacteristic, in a patient with a TAAA demands immediate evaluation; the aneurysm must be considered the cause until proven otherwise. If the source of the problem remains unexplained, aneurysm repair should be considered.

With regard to paraplegia, extent II aneurysms remain a major risk factor [9, 10]. This high-risk group of patients has benefitted the most from evolving refinements in operative technique and innovations in spinal cord protection. We have recently reported that the use of left heart bypass in patients with extent II TAAAs has reduced the incidence of paraplegia from 13.1% to 4.8% (p = 0.007) [11]. The emergence of diabetes as a predictor of paraplegia was unexpected, and the strength of this association was particularly surprising: the risk of paraplegia in diabetic patients with less extensive aneurysms was similar to that in nondiabetic patients with extent II aneurysms (Table 5). The damaging effects of diabetes on small peripheral arteries, the coronary arteries, and the retinal capillaries suggest that similar insults to the spinal cord’s blood supply may impair its ability to tolerate periods of ischemia.

Our previous analysis of 660 patients revealed that chronic dissection was not a risk factor for either early mortality or paraplegia after TAAA repair [12]. The current study confirms these findings: chronic dissection was not associated with death or paraplegia. Our models, therefore, can be applied in cases both with and without dissection. In contrast, the formula of Juvonen and associates is only applicable to patients without dissection, because patients with chronic distal dissection were excluded from the analysis [1]. Classically, TAAAs with dissection have been characterized as being more prone to rupture than those without dissection [13]. A prospective risk analysis focusing on the natural history of TAAAs with dissection would be a beneficial counterpart to the new operative risk models.

In conclusion, contemporary surgical management of TAAAs provides favorable results for patients who are acceptable candidates. When balanced with models predicting the probability of aneurysm rupture, the operative risk models presented above may assist in decisions regarding elective aortic repair. The predictive accuracy of these formulas, however, will require validation through prospective evaluations.


   Acknowledgments
 
We gratefully acknowledge Autumn Jamison for providing database management, statistical analysis, and invaluable assistance with manuscript preparation.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

  1. Juvonen T., Ergin M.A., Galla J.D., et al. Prospective study of the natural history of thoracic aortic aneurysms. Ann Thorac Surg 1997;63:1533-1545.[Abstract/Free Full Text]
  2. Coselli J.S. Thoracoabdominal aortic aneurysms. In: Yao J.S.T., Pearce W.H., eds. Techniques in vascular and endovascular surgery. Stamford: Appleton & Lange, 1998:211-224.
  3. Coselli J.S. Surgical technique, preoperative and intraoperative management of thoracoabdominal aortic aneurysm. In: Yao J.S.T., Pearce W.H., eds. Arterial surgery. Stamford: Appleton & Lange, 1996:223-235.
  4. Coselli J.S. Thoracoabdominal aortic aneurysm. In: Rutherford R.B., ed. Vascular surgery, 4th ed. Philadelphia: WB Saunders, 1994:1069-1087.
  5. Coselli J.S., LeMaire S.A., Ledesma D.F., Ohtsubo S., Tayama E., Nosé Y. Initial experience with the Nikkiso centrifugal pump during thoracoabdominal aortic aneurysm repair. J Vasc Surg 1998;27:378-383.[Medline]
  6. Crawford E.S., Crawford J.L., Safi H.J., et al. Thoracoabdominal aortic aneurysms. J Vasc Surg 1986;3:389-404.[Medline]
  7. Acher C.W., Wynn M.M., Hoch J.R., Popic P., Archibald J., Turnipseed W.D. Combined use of cerebral spinal fluid drainage and naloxone reduces the risk of paraplegia in thoracoabdominal aortic aneurysm repair. J Vasc Surg 1994;19:236-248.[Medline]
  8. Guidelines for data reporting and nomenclature for The Annals of Thoracic Surgery. Ann Thorac Surg 1988;46:260–1.
  9. Svensson L.G., Crawford E.S., Hess K.R., Coselli J.S., Safi H.J. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg 1993;17:357-370.[Medline]
  10. Acher C.W., Wynn M.M., Hoch J.R., Kranner P.W. Cardiac function is a risk factor for paralysis in thoracoabdominal aortic replacement. J Vasc Surg 1998;27:821-830.[Medline]
  11. Coselli J.S., LeMaire S.A. Left heart bypass reduces paraplegia rates following thoracoabdominal aortic aneurysm repair. Ann Thorac Surg 1999;67:1931-1934.[Abstract/Free Full Text]
  12. Coselli J.S., LeMaire S.A., Poli de Figueiredo L., Kirby R.P. Paraplegia after thoracoabdominal aortic aneurysm repair. Ann Thorac Surg 1997;63:28-36.[Abstract/Free Full Text]
  13. Coselli J.S., Poli de Figueiredo L.F. Natural history of descending and thoracoabdominal aortic aneurysms. J Card Surg 1997;12:285-291.[Medline]

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