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Ann Thorac Surg 1997;63:93-97
© 1997 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Operation for Nondissecting Aneurysm in the Descending Thoracic Aorta

Niigata University School of Medicine, Niigata; Hokkaido University School of Medicine, Sapporo; Sapporo Medical University School of Medicine, Sapporo; Tohoku University School of Medicine, Sendai; Chiba University School of Medicine, Chiba; Keio University School of Medicine, Tokyo; Tokyo Women's Medical College, Tokyo; National Nagoya Hospital, Nagoya; Oosaka University Medical School, Suita; Oosaka Prefectural Hospital, Oosaka; and National Cardiovascular Center, Suita, Japan

Accepted for publication July 15, 1996.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Background. Little is known about the risks of mortality and morbidity after descending thoracic aortic aneurysm repair using left heart bypass and temporary arterioarterial bypass.

Methods. A multicenter, retrospective study was performed on 120 patients who were admitted to one of nine cardiovascular centers between January 1988 and December 1993 and underwent operation for nondissecting thoracic aortic aneurysm. The present series included 10 patients with ruptured aneurysm. Graft replacement was performed in 95 patients, patch repair in 22, and suture of the ruptured aorta in 3. Venoarterial bypass was used in 45 patients, left heart bypass in 56, and temporary arterioarterial bypass in 19 as circulatory support. The mean postoperative follow-up period was 30 ± 21 months.

Results. Hospital mortality occurred in 7 patients (5.8%). Univariate analysis revealed that only aneurysmal rupture was related to hospital mortality. Brain or cord injury was observed in 4. Of nine deaths that occurred after discharge, five were related to aneurysm and two were due to vascular event. No significant difference was noticed in probability of survival according to the circulatory supporting method. Only aneurysmal rupture affected probability of survival. Multivariate analysis revealed that aneurysmal rupture was the only independent predictor for vascular death including hospital mortality.

Conclusions. The present study confirms that aneurysmal rupture is a significant predictor for mortality and morbidity in aortic operations for nondissecting descending thoracic aneurysm, and that a similarly good outcome would be expected when using left heart bypass, temporary arterioarterial bypass, or venoarterial bypass.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
For editorial comment, see page 9

Despite the recent decrease in mortality associated with descending thoracic aortic aneurysmal repair, potential risks of morbidity including cord injury still remain a serious issue [1–5]. Recently left heart bypass using a pump system has been reported as a useful adjunct for operation on the descending and thoracoabdominal aorta [2, 6]. Little is known about the risks of

For editorial comment, see page 9

mortality and morbidity and about the late survival after descending thoracic aneurysm repair using left heart bypass and temporary arterioarterial bypass. In this communication, we present little difference in outcomes according to the three methods of circulatory support-venoarterial bypass, left heart bypass, and temporary arterioarterial bypass-and analyze risks related to mortality and morbidity after operation for descending thoracic aortic aneurysm.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Of those who were admitted to one of nine Japanese cardiovascular centers between January 1988 and December 1993, 120 patients (93 men and 27 women) who underwent an aortic operation for nondissecting descending thoracic aneurysm were enrolled in the present study. Those who underwent aortic operation using selective cerebral perfusion or hypothermic circulatory arrest and those without circulatory support were not included. The age at operation ranged from 35 to 81 years, with a mean ± standard deviation of 64 ± 9 years. All cases were fusiform or saccular-type aneurysm due to an atherosclerotic or degenerative cause. Maximal aneurysmal diameter measured on computed tomogram or echoaortogram at admission ranged from 40 to 100 mm, with a mean of 60 mm. Baseline patient characteristics including demographics are described in Table 1. Ruptured aneurysm was confirmed when massive hematoma around the involved aorta was revealed at operation. Aneurysmal rupture was observed in 10 patients.

Follow-up and Statistics
Follow-up was completed on December 31, 1994. The mean postoperative follow-up period was 29.8 months. All data were collected from the patients' records in the institutions and input to Epson computer system Endeavor AT-500 using Microsoft Windows 3.1 J. Death due to any cause during the hospitalization was designated "hospital mortality." Details of neurologic deficits that were observed before or that occurred after the operation were also noted. All reoperations performed for residual aneurysm or for aortic complications were registered. The data were analyzed using the SPSS medical package (SPSS Inc). Continuous variables are expressed as the mean ± one standard deviation, and tested by unpaired t test for significance. Potential risks of mortality and morbidity were tested for significance by ²test and finally identified by multivariate regression analysis. The Kaplan-Meier method was used as a nonparametric estimation of survival differences between subgroups. The probability of survival was expressed as an estimate ± one standard error of the estimate, and comparison of curves was made by generalized Wilcoxon test. For all analyses, a p value of 0.05 or less was considered significant.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Hospital Mortality and Morbidity
Among 120 patients, 7 (5.8%) died during the hospitalization due to various causes including brain/spinal cord injury, myocardial infarction, and organ failure; the 30-day mortality rate was 3.3% (4 patients). Univariate analysis revealed that only aneurysmal rupture was related to hospital mortality (p = 0.0124) (Table 2). Brain or spinal cord injury occurred in 4 patients (3.3%) after the operation: paraplegia in 1 (with temporary arterioarterial bypass), cerebral infarction in 2 (with venoarterial bypass), and transient ischemic attack in 1 (with temporary arterioarterial bypass) (Table 3). Subsequently the second patient died during the hospitalization due to severe neurologic deficits. Circulatory support methods were unrelated to the incidence of neurologic deficits. Only aneurysmal rupture was found to be related to hospital mortality including neurologic disability (p = 0.0042).

View larger version (18K): [in this window] [in a new window]   Fig 1. . Probability of survival according to circulatory support method. No significant difference was noted among the three groups. (LHB = left heart bypass using mainly a centrifugal pump system; Temp B = temporary bypass using a heparin-coated circuit or centrifugal pump system;VAB = venoarterial bypass using standard cardiopulmonary bypass.)

View larger version (17K): [in this window] [in a new window]   Fig 2. . Probability of survival for ruptured and nonruptured aortic aneurysm. A significant difference was noted between the two survival curves.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
As recently pointed out by the group from Houston [7], distal aortic perfusion and hypothermia apparently improve the outcome of aortic operations on the descending thoracic aorta. The 30-day mortality in recent reports [2–8] ranged between 3% and 14.7%, and the incidence of cord injury including both paraplegia and paraparesis was between 0% and 23% in patients having descending thoracic or thoracoabdominal aortic operations. Both of these figures are similar to our results: 3.3% incidence of mortality and cord injury. The incidence of neurologic injury in these reports [2–7] seemed to vary with the circulatory support method, the location of the aortic aneurysm, the extent of aortic repair, and the year of operation. Verdant and associates [8] reported a 0% incidence of paraplegia with a 0.2% incidence of renal failure when analyzing 366 patients who underwent descending thoracic aneurysmectomy with the aid of a Gott shunt tube, and Kazui and colleagues [5] reported a 2% paraplegia rate with venoarterial bypass. However, in these two series, the early mortality rate was 12% and 14%, respectively, and it was unclear whether a potential cord injury was implicated or not in the hospital deaths. On the other hand, Borst and associates [2] reported a low mortality rate (3% at 30 days) together with an acceptable incidence of spinal cord injury (4.5%) in operations for descending thoracic aortic aneurysm using a left heart bypass technique. Although that report might encourage us to apply the technique, no significant differences in mortality and morbidity rates were found between the three circulatory support methods in the present series.

Respiratory dysfunction due to chronic pulmonary diseases is widely known as an risk factor for postoperative respiratory failure in the field of thoracic aortic surgery. In the present series, 8 patients (6.7%) showed a preoperative respiratory dysfunction. Two of them died after the operation, and 3 of 6 hospital survivors required a prolonged hospitalization of more than 2 months after the operation. Thus, respiratory function should be evaluated carefully in patients with associated pulmonary diseases and should be taken into consideration in selecting patients for elective thoracic aneurysm repair.

Various attempts have been made to avoid cord injury in extensive descending thoracic and thoracoabdominal aortic reconstruction, including intraoperative cord protection and reattachment of intercostal arteries [4, 7, 9]. In the present series, paraplegia developed in 1 patient. Details of adjuncts for cord protection were not recorded in the present study. A further clinical study is needed on cord injury in thoracic aortic operations.

In conclusion, the present study confirms that aneurysmal rupture is a significant predictor of mortality and morbidity in aortic operations for nondissecting descending thoracic aneurysm, and that similarly good outcomes would be expected when using left heart bypass, temporary arterioarterial bypass, or venoarterial bypass.

	Acknowledgments

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
This work was supported by Research Grant for Cardiovascular Diseases 4C-3 from the Japanese Ministry of Health and Welfare.

We thank Dr Hisanaga Moro and Dr Masa-aki Sugawara (Second Department of Surgery, Niigata University School of Medicine, Niigata, Japan) for help in the data collection and statistical analysis.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Address reprint requests to Dr Hayashi, Second Department of Surgery, Niigata University School of Medicine, 1-757 Asahimachidohri, Niigata city, 951, Japan.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

1. Dapunt OE, Galla JD, Sadeghi AM, et al. The natural history of thoracic aortic aneurysm. J Thorac Cardiovasc Surg 1994;107:1323–33.[Abstract/Free Full Text]
2. Borst HG, Jurmann M, Buhner B, Laas J. Risk of replacement of descending aorta with a standardized left heart bypass technique. J Thorac Cardiovasc Surg 1994;107:126–33.[Abstract/Free Full Text]
3. Kouchoukos NT, Daily BB, Rokkas CK, Murphy SF, Bauer S, Abboud N. Hypothermic bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg 1995;60:67–77.[Abstract/Free Full Text]
4. Shiiya N, Yasuda K, Matsui Y, Sakuma M, Sasaki S. Spinal cord protection during thoracoabdominal aortic aneurysm repair: results of selective reconstruction of the critical segmental arteries guided by evoked spinal cord potential monitoring. J Vasc Surg 1995;21:970–5.[Medline]
5. Kazui T, Komatsu S, Yokoyama H. Surgical treatment of aneurysms of the thoracic aorta with the aid of partial cardiopulmonary bypass: an analysis of 95 patients. Ann Thorac Surg 1987;43:622–7.[Abstract]
6. Biglioli P, Spirito R, Pompilio G, et al. Descending thoracic aorta aneurysmectomy: left-left centrifugal pump versus simple clamping technique. Cardiovasc Surg 1995;3:511–8.[Medline]
7. Safi HJ, Bartoli S, Hess KR, et al. Neurologic deficit in patients at high risk with thoracoabdominal aortic aneurysms: the role of cerebral spinal fluid drainage and distal aortic perfusion. J Vasc Surg 1994;20:434–43.[Medline]
8. Verdant A, Cossette R, Page A, Baillot R, Dontigny L, Page P. Aneurysms of the descending thoracic aorta: three hundred sixty-six consecutive cases resected without paraplegia. J Vasc Surg 1995;21:385–91.[Medline]
9. Fehrenbacher JW, McCready RA, Hormuth DA, et al. One-stage segmental resection of extensive thoracoabdominal aneurysms with left-sided heart bypass. J Vasc Surg 1993;18:366–71.[Medline]

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This Article Abstract 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): Keishu Yasuda Koichi Tabayashi Susumu Nakano Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hayashi, J.-i. Articles by Takamiya, M. Search for Related Content PubMed PubMed Citation Articles by Hayashi, J.-i. Articles by Takamiya, M. Related Collections Related Article