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Ann Thorac Surg 2000;69:414
© 2000 The Society of Thoracic Surgeons
Discussion
DR RANDALL B. GRIEPP (New York, NY): I would like to thank the Society for the opportunity to discuss this paper, and Dr Coselli for sending me his manuscript. This is an important paper. It is by far the largest contemporary series of surgical treatment at thoracoabdominal aneurysms. The careful tabulation of the results by Coselli and associates, plus modern statistical techniques, allow one, as they have pointed out, to now calculate risk factors for individual patients facing operation.
This is our equation for risk of rupture of thoracic and thoracoabdominal aneurysms that Dr. Coselli has alluded to, and this is the way we utilize this equation. It is very easy to put it into a PC so you can just plug in patient data and read out a risk of rupture. Dr Coselli’s formulae, which are contained in the body of the manuscript, allow one to do exactly the same thing for operative risk. Thus, one can calculate rupture risk and operative risk for an individual patient.
It should be pointed out, however, though that those are Coselli and associates’ results. It is probably not quite fair for all of us to tell our patients that we may accomplish the same thing. However, with a group analysis, one can enter one’s own patients in, see how one’s results compare with Coselli and associates’, and then apply a correction factor to arrive at the most honest estimate possible of the operative risk that your patient faces.
I would like to suggest one additional factor, however, and that is that we begin thinking a little bit about risk from the patient’s standpoint. When I sit down with a patient to discuss risk of operation, I find that he or she is usually not too interested in all of the horrible things that can happen, but rather the probability of a good outcome. That is: what is the chance of walking out of here in as good a shape as I came in? I would encourage Coselli and associates to utilize the data to give us those sorts of numbers for risk from the patient’s standpoint. The fields of paraplegia, death, and, to some extent, renal failure, overlap. It is of little interest to a patient if he dies in 5 days whether he has been paraplegic or anuric during that time. He is interested in the chances of getting out this alive and in good shape.
I would also like to take this opportunity, for my own benefit and perhaps for some other members of the Society, to ask Dr Coselli a few questions regarding the techniques that led to these wonderful results.
When is hypothermic circulatory arrest appropriate in the resection of these aneurysms? If feasible, is distal perfusion always advisable, or are there instances in which it can be dispensed with? When is visceral perfusion important in these resections?
And finally, I would like to bring up the question of paraplegia. Coselli and associates’ rate here for the type II aneurysms is 8.2%; our reported rate in a group of aneurysms with similar extent is 10%. We almost never put in intercostal arteries; they almost always do. What insights do they have to further reduce this 8%to 10% paraplegia rate.
I enjoyed this paper very much, and I salute Coselli and associates for the unique accomplishment that this series represents.
DR COSELLI: I would like to thank Dr Griepp for his very kind comments. We agree entirely that for an individual surgeon, it is important to evaluate and analyze your own data and results. Furthermore, there is the potential for the adjustment of risk coefficients for an individual practice or institution.
I also agree that it means very little to an individual patient, who dies 5 days postoperatively, whether or not that patient was paraplegic or anuric. However, for the analysis here, in the derivation of our formulas, we included all incidence of paraplegia including those with early mortality. This is justified, I believe, by virtue of providing a more accurate estimation. If, for example, we had excluded paraplegia in patients with early mortality, it would underestimate the overall incidence of paraplegia and possibly downplay operative risk.
We use hypothermic circulatory arrest in those patients in whom proximal cross-clamping cannot be achieved safely for anatomic reasons. We have not used circulatory arrest specifically for purposes of visceral and spinal cord protection.
I use distal aortic perfusion almost exclusively in patients with extent I and II aneurysms. I have not used left heart bypass or distal aortic perfusion routinely in patients of lesser extent, ie, extent III and IV. In patients with extent I or II aneurysms in whom left heart bypass is employed and the origins of the visceral and renal vessels are exposed, we have supplemented the technique with direct visceral perfusion using catheters placed within the origin of these branch vessels.
There has been an overall general trend towards a reduction in the incidence of postoperative paraplegia after thoracoabdominal aortic aneurysm surgery across the board, including Dr Griepp’s group at Mt. Sinai, our group, and others. It would be overly simplistic to represent this overall reduction in operative risk, with regards to neurological deficits, entirely to a single aspect such as the reattachment of intercostal arteries. Along with this overall trend, there has been one of increasing expertise and experience by a large number of surgeons. Consequently, any single specific aspect of technique and surgical approach assumes lesser importance. It has been our approach to place emphasis on the importance of reattachment of intercostal arteries. In a given patient, it is difficult to determine which intercostal arteries are the ones that are most important; consequently, I have been rather aggressive in reattaching as many as possible in the region from T7 to L1.
Again, I would like to thank the Society for the opportunity to present this material.
Related Article
Ann. Thorac. Surg. 2000 69: 409-414.
This article has been cited by other articles:
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  S. A. LeMaire, C. C. Miller III, L. D. Conklin, Z. C. Schmittling, C. Koksoy, and J. S. Coselli A new predictive model for adverse outcomes after elective thoracoabdominal aortic aneurysm repair Ann. Thorac. Surg., April 1, 2001; 71(4): 1233 - 1238. [Abstract] [Full Text] [PDF]
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