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Ann Thorac Surg 2007;83:S862-S864
© 2007 The Society of Thoracic Surgeons
The Texas Heart Institute at St. Lukes Episcopal Hospital and Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
* Address correspondence to Dr LeMaire, One Baylor Plaza, BCM 390, Houston, TX 77030. (Email: slemaire{at}bcm.edu).
Presented at Aortic Surgery Symposium X, New York, NY, April 2728, 2006.
| Abstract |
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METHODS: Since 1986, 2286 patients have undergone open repair of thoracoabdominal aortic aneurysms on our service. Of these, 1662 patients (72.7%) had degenerative aneurysms without dissection, 78 (3.4%) had acute aortic dissection, and 546 (23.9%) had chronic dissection. There were 139 ruptured aneurysms (6.1%). Extensive repairs (ie, Crawford extents I and II) were performed in 1468 patients (64.2%). Segmental intercostal or lumbar arteries were reattached in 1401 patients (61.3%), left heart bypass was used in 909 (39.8%), and cerebrospinal fluid drainage was used in 615 (26.9%).
RESULTS: The 30-day survival rate was 95.0% (2171 patients). Renal failure requiring hemodialysis occurred in 129 patients (5.6%), and paraplegia or paraparesis developed in 87 patients (3.8%). Patients who underwent replacement of the entire thoracoabdominal aorta (extent II) had the highest rates of death (6.0%), spinal cord deficit (6.3%), and renal failure (8.3%).
CONCLUSIONS: Current management strategies enable patients to undergo conventional open thoracoabdominal aortic aneurysm repair with excellent early survival and acceptable morbidity.
| Introduction |
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| Patients and Methods |
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Repairs were performed in 1355 men (59.3%) and 931 women (40.7%). The mean patient age was 66.1 years (range, 18 to 88 years; median, 69 years). Cardiovascular risk factors included hypertension in 1733 patients (75.8%), diabetes in 130 (5.7%), cerebrovascular disease in 254 (11.1%), and coronary artery disease in 825 (36.1%). Chronic lung disease was present in 843 patients (36.9%). Renal insufficiency was present in 313 patients (13.7%), 39 of whom were being treated with hemodialysis. Previous procedures included coronary angioplasty or coronary artery bypass grafting in 400 patients (17.5%) and thoracic aortic surgery in 578 (25.3%).
The extent of each repair was categorized according to the original Crawford classification system [10] (Fig 1). Extensive TAAA repairs (ie, Crawford extents I and II) were performed in 1468 patients (64.2%). The majority of patients (1662, 72.7%) had degenerative aneurysms without dissection, 78 (3.4%) had acute aortic dissection, and 546 (23.9%) had chronic dissection. Aneurysm-related symptoms were present in 1474 patients (64.5%) but were acute in only 254 (11.1%). There were 139 ruptured TAAAs (6.1%).
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Segmental intercostal and lumbar arteries were reattached to the graft in 1401 patients (61.3%). Cerebral spinal fluid drainage was used in 615 patients (26.9%) [13]. We used left heart bypass with a centrifugal pump in 909 patients (39.8%); in most cases, this adjunct was used only during the proximal anastomosis [14]. During the remainder of the repair, whenever possible, the left heart bypass circuit was used to provide selective perfusion (through balloon catheters) to the celiac and superior mesenteric arteries, whereas the renal arteries were intermittently perfused with cold (4°C) crystalloid [15].
| Results |
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Stratified early results based on the extent of repair are listed in Table 1. Patients who underwent replacement of the entire thoracoabdominal aorta (extent II) had the highest rates of death, spinal cord deficit, and renal failure.
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| Comment |
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Despite these improvements, managing patients during and after TAAA operations remains challenging; patients with substantial comorbidity and extensive aneurysms remain at high risk for postoperative complications. Patients who undergo replacement of the entire thoracoabdominal aorta (extent II) continue to exhibit the highest rates of early death, spinal cord deficit, and renal failure [19].
As the population ages and diagnostic capabilities improve, elderly patients with relatively limited physiologic reserve are increasingly being referred for treatment of TAAAs. The resulting need for new strategies to further reduce the morbidity and mortality associated with TAAA repair has made potential endovascular approaches particularly attractive.
Ongoing progress in endovascular techniques will undoubtedly alter our approach to TAAA repair, especially in patients who are poor candidates for open repair. Experience with pure endovascular treatment of TAAAs remains limited and purely experimental [69]; however, hybrid approaches that combine open visceral bypass with endoluminal TAAA exclusion are rapidly accumulating [15]. Although still essentially anecdotal, current reports suggest that TAAA patients with limited physiologic reserve can be treated successfully by combining open and endovascular repairs. These hybrid procedures are clearly feasible and seem to be associated with reductions in postoperative morbidity and mortality, but the durability of these repairs is unclear. Still, as endograft design and endovascular techniques continue to improve, combined approaches are likely to play an increasingly important role in the treatment of TAAAs.
In conclusion, our findings show that contemporary management strategies enable patients to undergo conventional open TAAA repair with excellent early survival and acceptable morbidity. We anticipate that these data, along with other contemporary series, will serve as a basis for comparison as endovascular approaches continue to evolve.
| Acknowledgments |
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| References |
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