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Ann Thorac Surg 2007;83:S862-S864
© 2007 The Society of Thoracic Surgeons

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Supplement

Open Surgical Repair of 2286 Thoracoabdominal Aortic Aneurysms

The Texas Heart Institute at St. Luke’s 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 27–28, 2006.

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
BACKGROUND: As endovascular approaches to thoracoabdominal aortic repairs continue to evolve, careful assessment of the safety and efficacy of these alternative approaches will require comparison with standard open surgical repair. The purpose of this report is to update our experience with conventional open repair of thoracoabdominal aortic aneurysms.

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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Recent endovascular innovations have led to alternative approaches for repairing thoracoabdominal aortic aneurysms (TAAAs). For example, several groups have reported using hybrid approaches in which open visceral bypass grafting secures organ perfusion and subsequent stent graft placement achieves endoluminal exclusion of the entire TAAA [1–5]. These and other advances in endovascular techniques—including the development of fenestrated and branched endografts [6–9]—are certain to affect our approach to managing these extensive aneurysms. Careful assessment of the safety and efficacy of these alternative approaches will require comparison with standard open surgical repair. The purpose of this report is to update our experience with open repair of TAAAs.

	Patients and Methods

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Patients
Since 1986, perioperative data from 2286 consecutive open TAAA repairs performed by our service have been collected and entered into a clinical database. Retrospective review of this database and waiver of informed consent were approved by the Institutional Review Board at Baylor College of Medicine.

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%).

View larger version (57K): [in this window] [in a new window]   Fig 1. Drawing illustrates the Crawford classification of thoracoabdominal aortic aneurysm repairs, according to the location and extent of aorta replaced in continuity. Extent I repairs involve most, or all, of the descending thoracic aorta and the upper abdominal aorta. Extent II repairs involve most, or all, of the descending thoracic aorta and extend into the infrarenal abdominal aorta. Extent III repairs involve the distal half, or less, of the descending thoracic aorta and varying portions of the abdominal aorta. Extent IV repairs involve most, or all, of the abdominal aorta.

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

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
There were 150 operative deaths (6.6%), including 115 patients (5.0%) who died within 30 days of the procedure. Pulmonary complications—the most common form of morbidity—occurred in 734 patients (32.1%). Other complications included cardiac events in 181 patients (7.9%), renal failure requiring hemodialysis in 129 (5.6%), paraplegia or paraparesis in 87 (3.8%), and stroke in 40 (1.7%). Bleeding requiring a return to the operating room occurred after 57 TAAA repairs (2.5%).

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.

	Comment

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

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 [6–9]; however, hybrid approaches that combine open visceral bypass with endoluminal TAAA exclusion are rapidly accumulating [1–5]. 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

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The authors gratefully acknowledge Scott Weldon, MA, for creating the medical illustration, and Stephen N. Palmer, PhD, ELS, for providing editorial support.

	References

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Joseph S. Coselli John Bozinovski Scott A. LeMaire Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Coselli, J. S. Articles by LeMaire, S. A. Search for Related Content PubMed PubMed Citation Articles by Coselli, J. S. Articles by LeMaire, S. A. Related Collections Great vessels