Twenty-eight-Year Experience With Ruptured and Symptomatic Type I-III Thoracoabdominal Aortic Aneurysms at a Large Tertiary Referral Center

Abstract

Given the relative rarity of ruptured and symptomatic type I-III thoracoabdominal aortic aneurysms (TAAA), there are few data of the outcomes of those who survive to repair. The goal of this study was to determine short- and long-term outcomes after open repair of type I-III TAAA for ruptured and symptomatic TAAAs and to compare the results with elective TAAA repairs. All open type I-III TAAA repairs performed from 1987 to 2015 were evaluated in an institutional database. Charts were retrospectively evaluated for perioperative outcomes: major adverse event, in-hospital death, SCI, and long-term survival. Univariate analysis was performed using the Fisher exact test for categorical variables and analysis of variance for continuous variables. Logistic regression was used for in-hospital end points; survival analysis was performed with Cox proportional hazards modeling and Kaplan-Meier techniques. During the study period, 516 patients had an open type I-III TAAA repair; 59 (11.4%) were performed for rupture, and 51 (9.9) were performed for symptomatic aneurysm. Ruptured and symptomatic groups were more likely to be older and female and to have larger presenting aortic diameters. The majority of ruptured and symptomatic cases were transferred from an outside facility (59.3% and 54.9%, respectively). Intraoperatively, the elective cohort was more likely to receive left-sided heart bypass as an operative adjunct; ruptures were less likely to receive a renal bypass, and operative time was highest for the elective cohort. Perioperative mortality was 18.6% for ruptured, 2.0% for symptomatic, and 7.4% for elective indications. Ruptures were most likely to require new hemodialysis after repair (20.3% vs 10.3% for elective; P = .02). On adjusted analysis, ruptures were more likely to suffer from perioperative death (adjusted odds ratio [AOR], 4.5; 95% confidence interval [CI], 1.7-11.4) and major adverse events (AOR, 2.8; 95% CI, 1.4-5.4). Rupture and symptomatic aneurysm were not independently associated with SCI; however, preoperative hemodynamic instability was predictive (AOR, 8.7; 95% CI, 1.7-44.2). Both rupture and symptomatic cases were associated with decreased survival on Kaplan-Meier analysis with 5-year survival for ruptures at 35%, symptomatic at 47.7%, and elective at 63.7% (P < .001). Adjusted hazards of death were 1.2 (95% CI, 0.9-1.8) in the symptomatic cohort and 2.3 (95% CI, 1.5-3.7) in the ruptured cohort. Open ruptured and symptomatic type I-III TAAA repairs can be performed with acceptable morbidity and mortality. Most symptomatic and rupture repairs were performed after transfer from another institution. Postoperative SCI is most strongly related to the preoperative hemodynamic status of the patient.