PC004 Early and Late Results of Reconstruction With Renal and Visceral Bypasses During Open Thoracoabdominal Aortic Aneurysm Repair

Abstract

Open thoracoabdominal aneurysm (TAA) repair remains an important treatment option for medically fit patients and those with connective tissue disease. In an effort to prevent delayed patch aneurysm of visceral segments, we perform reconstruction using individual long bypass grafts to visceral and renal vessels, arising proximal to the site of intercostal patches (Fig). The aim of this study was to evaluate immediate and long-term outcomes of this strategy for open thoracoabdominal aortic aneurysm (TAAA) repair and specifically of the visceral/renal bypasses (VRBs). Data from consecutive patients undergoing open TAAA repair with VRBs between 2002 and 2015 were retrospectively reviewed. Demographic and anatomic data, operative details, mortality, morbidity, and long-term follow-up specifically evaluating visceral/renal branch vessel patency were analyzed. There were 98 patients, 65 male and 33 female, with a median age of 61.5 years (interquartile range, 46.5-72 years); with 7 type I, 68 type II, 13 type III, and 9 type IV TAAAs. Connective tissue disorder was identified in 28 patients (29%) and dissection in 61 (62%). Mean Society for Vascular Surgery/American Association for Vascular Surgery comorbidity score was 7.5 (95% confidence interval, 6.3-8.6). Repairs were elective in 83 patients (85%); deep hypothermic circulatory arrest (DHCA) was used in 83 of 89 (93%) type I to III and in no type IV TAAAs. Spinal drainage was performed in 29 (30%). All repairs included VRBs; median number of intercostal artery pairs reimplanted was three (interquartile range, 2-4 pairs). Overall 30-day mortality was 11%. Morbidity among patients repaired with and without DHCA respectively was paraplegia (3% vs 13%), stroke (6% vs 8%), myocardial infarction (1% vs 13%), and renal failure requiring hemodialysis (11% vs 33%; 2% permanent). Mean length of clinical follow-up was 30 months (range, 1-164 months). Mean imaging follow-up, available in 70 patients, was 30 months (range, 1-148 months). Overall VRB graft patency at follow-up was 95%: celiac, 98%; superior mesenteric artery, 98%; renal, 94; and accessory renal, 75% (3 of 4). Patency of intercostal patches was 92% with aneurysmal degeneration in two patches; one successfully treated with endograft repair at 3 years. TAAA repair with debranching of visceral and renal vessels with long bypasses can be safely performed under DHCA, with acceptable early mortality and morbidity. Long-term patency of these bypasses is excellent with the advantage of avoidance of patch aneurysms.