Open Thoracoabdominal Aortic Aneurysm Research Articles

Cool-shot Technique to Protect Spinal Cord During Thoracoabdominal Aortic Replacement.

Deep hypothermia helps protect the spinal cord, but is invasive. Here, we present a method to avoid reperfusion injury by selectively circulating cold blood under high pressure to the intercostal artery during reperfusion after intercostal artery reconstruction. Of the 23 patients who underwent thoracoabdominal aortic aneurysm open repair, one died. The motor evoked potential disappeared during aortic clamping in nine patients. Six patients recovered completely from aortic clamping release, two showed recovery >50% and one achieved full recovery three months later. Permanent motor impairment did not occur. This method could prevent reperfusion injury and paraplegia following thoracoabdominal aortic aneurysm surgery.

Risk factors of 30-day and long-term mortality and outcomes in open repair of thoracoabdominal aortic aneurysm

BackgroundOpen repair of thoracoabdominal aortic aneurysm (TAAA) was characterized by significant risk of postoperative mortality and morbidity. The aim of this study was to determine the perioperative predictors of early and long-term mortality in patients undergoing open repair of TAAA. Besides, the postoperative outcomes in patients with open repair of TAAA were described.MethodsThis is a single-center retrospective study, and 146 patients with open repair of TAAA from January 4, 2011, to November 22, 2018 was involved. Categorical variables were analyzed by the Chi-square test or Fisher’s exact test, and continuous variables were analyzed by the independent sample t-test and the WilCoxon rank-sum test. Multivariate Logistic regression and Cox regression were applied to identify the predictors of 30-day and long-term mortality, respectively. The Kaplan Meier curves were used to illustrate survival with the Log-rank test.ResultsThe 30-day mortality was 9.59% (n = 14). Older than 50 years, the intraoperative volume of red blood cell (RBC) and epinephrine use were independently associated with postoperative 30-day mortality in open repair of TAAA. Long-term mortality was 17.12% (n = 25) (median of 3.5 years (IQR = 2–5 years) of follow-up). Prior open thoracoabdominal aortic aneurysm (TAAA) repair, aortic cross-clamping (ACC) time, intraoperative volume of RBC and use of epinephrine were independently correlated with long-term mortality.ConclusionsIdentifying perioperative risk factors of early and long-term mortaliy is crucial for surgeons. Intraoperative volume of RBC and use of epinephrine were predictors of both early and long-term mortality. In addition, patients of advanced age, prior open repair of TAAA and prolonged ACC time should be paid more attention.

The Impact of Sarcopenia in the Long-Term Survival of Patients following Complex Endovascular Aortic Surgery for Thoracoabdominal Aortic Aneurysms.

Image-based sarcopenia has been the subject of recent studies, hypothesized as a prognostic factor for patients with thoracoabdominal aortic aneurysms. We conducted a single-center retrospective analysis of patients who underwent complex endovascular repair for thoracoabdominal aortic aneurysms between 2008 and 2016. CT image assessment was performed and patients were classified as sarcopenic and non-sarcopenic using two stratification methods: skeletal mass index (SMI) and total psoas muscle index (TPMI). According to sex, each patient was defined as sarcopenic if their SMI or TPMI was in the lowest third of the study group. The primary endpoint was impact of sarcopenia on perioperative mortality and long-term survival. Secondary endpoints were perioperative complications. From a total of 155 patients, 135 were eligible for study. Overall, in-hospital mortality was 5.9% (8/135). The 30-day, 1-year, 3-year and 5-year mortality was 10.4% (14/135), 20% (27/135), 28.1% (38/135) and 31.1% (42/135), respectively. There was no difference in the long-term mortality rates between sarcopenic and non-sarcopenic patients regardless of the stratification method used (p = 0.4 for SMI and p = 0.2 for TPMI). According to SMI, 30-day mortality of sarcopenic patients was significantly lower in comparison to non-sarcopenic patients (1/45, 2.2% vs. 13/90, 14.4%, p = 0.028). Based on the total psoas muscle index, sarcopenic patients were at higher risk for development of pulmonary complications in comparison to non-sarcopenic patients postoperatively (p = 0.03). Using SMI and TPMI, sarcopenia was not associated with reduced long-term survival in patients undergoing complex endovascular repair for thoracoabdominal aortic aneurysms.

Utility of Motor Evoked Potentials in Contemporary Open Thoracoabdominal Aortic Repair

Paraplegia remains one of the major complications of contemporary open thoracoabdominal aortic aneurysm (TAAA) repair. Intraoperative motor-evoked potentials (MEPs) act as a surrogate measure for spinal cord homeostasis. The purpose of this study was to evaluate the results of intraoperative neuromonitoring in contemporary TAAA repair and its association with postoperative spinal cord ischemia. Patients who underwent open type 2 or 3 TAAA or completion aortic repair utilizing intraoperative neuromonitoring were identified between May 2006 and November 2023. Patient demographics, comorbidities, indication for the procedure, procedural details, and outcomes were recorded. The groups were divided based on type of repair, and univariate statistics were then utilized to evaluate the association of these metrics versus the type of repair. Seventy-nine patients underwent open type 2 (N=41) and 3 (N=23) TAAA and completion aortic (N=15; open in 14, endovascular in 1) repairs by a single surgeon. The cohort was predominantly male (N=48, 60.8%) with a mean age of 52.5±16.2 years. There was a high incidence of hypertension (N=53, 67.1%), smoking history (N=42, 53.1%), and connective tissue disorders (N=37, 46.8%). Operative indications included dissection-related (N=50, 63.3%) and degenerative (N=26, 32.9%) TAAA and dissection-related malperfusion (N=3, 3.8%). Left heart bypass was often (N=73, 92.4%) utilized for distal aortic perfusion, and cerebrospinal fluid drainage (N=77, 97.5%) was a common adjunct. MEPs were classified as no change (N=43, 54.4%), reversible change (N=26, 32.9%), irreversible change (N=4, 5.1%), and unreliable (N=6, 7.6%). MEP changes were predominantly bilateral (N=70, 88.6%) and occurred most often during repair of the abdominal aortic segment (N= 13, 16.5%). The median number of replaced vertebral levels was associated with MEP changes (P=0.013). SCI was only observed in repairs greater than 6 replaced vertebral levels with an overall frequency of 17.7%. It was most prevalent in completion aortic repairs (26.7%). Immediate and delayed SCI occurred in 10.1% and 7.6% of patients, respectively; it was most commonly (71.8%) reversible. Permanent paraplegia occurred in 4 patients (5.1%), with equal immediate and delayed onsets. MEPs demonstrated poor sensitivity (53.9%) and specificity (62.3%) for SCI, however there was a high negative predictive value (86.4%) in this population. In-hospital mortality occurred in 5 (6.3%). No changes in intraoperative MEPs are highly predictive of spinal cord homeostasis. The number of replaced vertebral levels and previous aortic repair should guide intraoperative neuroprotective measures including intercostal reimplantation and should take precedence over intraoperative monitoring, especially when MEP changes occur.

Early and mid-term outcomes of open thoracoabdominal aortic aneurysm repair after thoracic endovascular aortic repair

ObjectiveTo evaluate the early and mid-term outcomes of open repair in patients with thoracoabdominal aortic aneurysm (TAAA) after thoracic endovascular aortic repair (TEVAR).MethodsThis was a retrospective single center study. Data were retrospectively collected and analyzed for consecutive patients undergoing open TAAA repair (TAAAR) after TEVAR from November 2016 to June 2021. Indications for TAAAR included aneurysm progression due to endoleak, persisted false lumen perfusion, proximal/distal disease progression, and aorta rupture. The risk factor of operative mortality was analyzed by multivariable logistic regression model and the survival was evaluated by Kaplan–Meier.ResultsSixty-three patients who met the inclusion criteria for the study were identified. The mean age at TAAAR was 41 ± 12 years and 43 (68.3%) were male. Marfan syndrome (MFS) was presented in 39 patients (61.9%). 60 (95.2%) patients presented with post-dissection aneurysm and 3 (4.8%) patients with degenerative aneurysm. The extent of TAAA was Crawford I in 9 (14.3%), II in 22 (34.9%), III in 23 (36.5%), and IV in 9 (14.3%). Emergent TAAAR was done in 10 (15.9%) patients, and deep hypothermic circulatory arrest was used in 22 (34.6%). Endograft was explanted in 31 (49.2%). Operative mortality was 11 (17.5%). Stroke, paraplegia, and acute kidney failure occurred in 5 (7.9%), 7 (11.1%), and 6 (9.5%) patients, respectively. Pulmonary complications occurred in 19 (30.2%) patients. The estimated survival was 74.8 ± 4.9% at 5 years. Late reoperations were performed in 2 patients at 2.5 years and 1.3 years, respectively.ConclusionsIn this series of TAAA after TEVAR, TAAAR was related with a high risk of operative mortality and morbidity and the midterm outcomes represented a durable treatment and were respectable.

Intercostal Artery Re-Implantation in Thoraco-Abdominal Aortic Aneurysm Surgery

Intercostal Artery Re-Implantation in Thoraco-Abdominal Aortic Aneurysm Surgery

Posttraumatic stress disorder and quality of life in patients after open thoracoabdominal aortic repair.

Background: Open thoracoabdominal aortic aneurysm (TAAA) repair is often related to significant morbidity and complications like paraplegia or acute kidney injury. Subsequently, prolonged intensive care stay is common. However, there is a lack of research on post-traumatic stress disorder (PTSD) and the perceived quality of life (QOL) in patients undergoing complex aortic procedures, such as open TAAA repair. Therefore, our study aims to determine the prevalence of PTSD and the current QOLin these patients and whether it is associated with demographic factors or complications following open thoracoabdominal aortic repair. Patients and methods: In this retrospective study, a total of 213 adult surviving patients after open thoracoabdominal aortic repair were contacted with two questionnaires one to assess PTSD and another to evaluate current QOL after open thoracoabdominal aortic repair. 61 patients returned one or both the questionnaires, and 59 patients (97%) answered all questions of the 4-item primary care PTSD section of the survey. In addition to the PTSD screening, patients were sent an SF-36 questionnaire to assess their current quality of life. 60 patients answered the SF-36 questionnaire partially or completely (98%). Results: 27% of patients (16/59) screened positive for PTSD. Electronic medical records were matched to all responding patients. Patients who were screened positive for PTSD spent more days in intensive care (OR, 1.073; 95% CI 1.02-1.13; p=0.005), had a higher frequency of tracheotomy (OR, 6.43; 95% CI 1.87-22.06; p=0.004), sepsis (OR, 5.63; 95% CI 1.56-20.33; p=0.014), as well as postoperative paraparesis (OR, 13.23; 95% CI 1.36-129.02; p=0.019). In patients with postoperative complications, a statistically significant decrease in the overall score was observed for certain categories of the SF-36. Conclusions: The prevalence of PTSD is higher, in comparison to the general population's prevalence, and the quality of life is affected following open thoracoabdominal aortic aneurysm repair, with a significant relation to postoperative complications as well as the length of ICU stay. Further research and screening for PTSD in relation to open TAAA repair is needed to assess its role in patient QOL during follow up.

Discussion to: The severity of chronic obstructive pulmonary disease is associated with adverse outcomes after open thoracoabdominal aortic aneurysm repair

Discussion to: The severity of chronic obstructive pulmonary disease is associated with adverse outcomes after open thoracoabdominal aortic aneurysm repair

Simultaneous upper and lower body perfusion using hypothermia during thoracoabdominal aortic surgery

BackgroundIn open thoracoabdominal aortic aneurysm (TAAA) repair, we have been performing vascular reconstruction under moderate to deep hypothermia and assisted circulation using simultaneous upper and lower body perfusion. This method is effective for protecting the spinal cord and the brain, heart, and abdominal organs and for avoiding lung damage.MethodsTAAA repair was performed under hypothermia at 20–28 °C in 18 cases (Crawford type I in 0 cases, type II in 5, type III in 3, type IV in 4, and Safi V in 6) between October 2014 and January 2023. Cardiopulmonary bypass was conducted by combined upper and lower body perfusion, with perfusion both via the femoral artery and either transapically or via the descending aorta or the left brachial artery.ResultsThe ischemic time for the artery of Adamkiewicz and the main segmental arteries was 40–124 min (75 ± 33 min). No spinal cord ischemic injury or brain or heart complications occurred. One patient with postoperative right renal artery occlusion and one with an infected aneurysm required tracheostomy, but the intubation time for the other 16 was 32 ± 33 h. The duration of postoperative intensive care unit stay was 6.5 ± 6.2 days, the length of hospital stay was 29 ± 15 days, and no in-hospital deaths occurred.ConclusionsSimultaneous upper and lower body perfusion under moderate to deep hypothermia during thoracoabdominal aortic surgery may avoid not only spinal cord injury, but also cardiac and brain complications.

Outcomes of open repair for descending thoracic and thoracoabdominal aortic aneurysm in recent 10 years: experience of a high-volume centre in Korea.

Although recent studies and guidelines suggest the preferred outcomes after surgical repair of thoracic aortic aneurysm (TAA) and thoracoabdominal aortic aneurysm (TAAA), published results are limited to those from high-volume hospitals and based on old data gathered before optimal management was established. Here, we analysed our outcomes over the previous 10 years from cases of open TAA and TAAA repair to offer updated and real-world results of those complex procedures performed in a high-volume centre. From November 2013 to April 2022, 212 consecutive adult patients who underwent open TAA and TAAA repair were enrolled. We analysed early and late outcomes after surgery, including postoperative complications and mortality. There were 154 (73%) men, and the median age at surgery was 61 years. Intraoperative death occurred in 1 patient due to uncontrolled bleeding. Nine patients (4%) died during follow-up, and the survival estimates at 5 years were 94 ± 3% and 95 ± 3% after descending TAA and TAAA repair, respectively. Ten patients (4%) suffered from spinal cord ischaemic injury (9 with paraplegia and 1 with paresthesia), but permanent paraplegia persisted in only 1 case. We report very low postoperative complication rates and excellent early and late survival rates after open TAA and TAAA repair from our recent 10-year data analysis. These findings may assist when choosing treatment options for these complicated diseases.

The severity of chronic obstructive pulmonary disease is associated with adverse outcomes after open thoracoabdominal aortic aneurysm repair

ObjectiveWe assessed associations between outcomes after open thoracoabdominal aortic aneurysm (TAAA) repair and preoperative airflow limitation stratified by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) spirometric classification of chronic obstructive pulmonary disease (COPD) severity. MethodsAmong 2368 open elective TAAA repairs in patients with spirometric data, 1735 patients had COPD and 633 did not. Those with COPD were stratified by preoperative respiratory dysfunction as GOLD 1 (forced expiratory volume in the first second of expiration [FEV1] ≥80% of predicted; n = 228), GOLD 2 (50% ≤ FEV1 < 80% of predicted; n = 1215), GOLD 3 (30% ≤ FEV1 < 50% of predicted; n = 260), or GOLD 4 (FEV1 < 30% of predicted; n = 32). Early outcomes included operative mortality and adverse events (operative death or persistent stroke, spinal cord deficit, or renal failure requiring dialysis); associations of outcomes were determined using logistic regression models. Kaplan–Meier analysis compared late survival by the log-rank test. ResultsPulmonary complications occurred in 38.4% of patients with COPD versus 30.0% without COPD (P < .001). Operative mortality and adverse events were more frequent in patients with COPD than without COPD (7.9% vs 3.8% [P < .001] and 14.9% vs 9.8% [P = .001], respectively). Worsening GOLD severity was independently associated with operative death and adverse event. Survival was poorer in patients with COPD than in those without (61.9% ± 1.2% vs 73.6% ± 1.8% at 5 years; P < .001), particularly in patients with increasing GOLD severity (68.7% ± 3.2% vs 63.7% ± 1.4% vs 51.4% ± 3.2% vs 31.3% ± 8.2% at 5 years; P < .001). ConclusionsPatients with COPD are at elevated risk for operative death and adverse events. Staging by GOLD severity aids preoperative risk stratification. Patients with airflow limitations may benefit from optimization before TAAA repair.

Outcomes of thoracoabdominal aortic aneurysm repair in patients with a previous myocardial infarction

ObjectiveMany patients undergoing thoracoabdominal aortic aneurysm (TAAA) repair have had a previous myocardial infarction (MI). To address the paucity of data regarding outcomes in such patients, we aimed to compare outcomes after open TAAA repair in patients with and without previous MI. MethodsFrom 1986 to 2022, we performed 3737 consecutive open TAAA repairs. Of these, 706 (18.9%) were in patients with previous MI. We used multivariable logistic regression to identify predictors of operative death. Propensity score matching analyzed preoperative and select operative variables to create matched groups of patients with or without a previous MI (n = 704 pairs). Late survival was determined by Kaplan–Meier analysis and compared by log rank test. ResultsOverall, operative mortality was 8.5% and the adverse event rate was 15.2%; these were elevated in patients with MI (11.0% vs 7.9% [P = .01] and 18.0% vs 14.6% [P = .02], respectively). In the propensity score–matching cohort, the MI group had a greater rate of cardiac complications (32.4% vs 25.4%; P = .005) and delayed paraparesis (5.1% vs 2.4%; P = .1); however, there was no difference in operative mortality (11.1% vs 10.9%; P = 1) or adverse event rate (18.0% vs 16.8%; P = .6). Overall, previous MI was not independently associated with operative mortality in multivariable analysis (P = .1). The matched MI group trended toward poorer 10-year survival (29.8% ± 1.9% non-MI vs 25.0% ± 1.8% MI; P = .051). ConclusionsAlthough previous MI was not associated with early mortality after TAAA repair, patients with a previous MI had greater rates of cardiac complications and delayed paraparesis. Patients with a previous MI also trended toward poorer survival.

Current approaches to spinal cord protection during open thoracoabdominal aortic aneurysm repair.

Spinal cord deficit (SCD) is a feared complication after thoracoabdominal aortic aneurysm repair. Vigilant management throughout the perioperative period is necessary to reduce the risk of SCD. Measures for preventing SCD during the intraoperative period include preoperative optimization and recognizing patients at a higher risk of SCD. In this manuscript, we discuss intraoperative adjuncts including utilization of cerebrospinal fluid drainage, left heart bypass, mild hypothermia, selective reimplantation of intercostal and lumbar arteries, and renal and visceral vessel perfusion. From the operative to the postoperative period, careful attention to avoiding hypotension and anemia is important. If SCD is recognized early, therapeutic intervention may be implemented to mitigate injury.

The result of prospective evaluation of 3-dimensional printing-aided extensive thoracoabdominal aorta repair.

Paraplegia is a distressing complication after open thoracoabdominal aortic aneurysm (TAAA) repair, and revascularization of T8-L2-level segmental arteries is considered pivotal to prevent paraplegia. We employed 3-dimensional (3D) printing to efficiently revascularize segmental/visceral arteries and prospectively evaluated its safety and efficacy. From January 1, 2020, to June 30, 2022, we prospectively enrolled patients of extent I, II, or III TAAA repair. Guidance models were 3D-printed based on preoperative computed tomography, and multibranched aortic grafts were manually constructed upon this model before surgery. The composite outcome of operative mortality, permanent stroke, and permanent spinal cord deficit (SCD) was compared with the historical control group (n=77, in 2015-2020), subjected to similar TAAA repair without 3D printing. A total of 38 patients (58.6± 13.2years) underwent open TAAA repair with the aid of 3D printing. Extent I, II, and III repairs were performed in 14 (36.8%), 17 (44.7%), and 7 (18.4%), respectively. Concomitant arch repair and bi-iliac reconstruction were performed in 7 (18.4%) and 6 patients (15.8%), respectively. Mean pump time was 107.7± 55.5minutes. Operative mortality, permanent stroke, and permanent SCD each occurred in 1 patient (2.6%), and the incidence of the composite outcome was 7.9% (3/38). In the control group, mean pump time was 166.0± 83.9minutes, significantly longer than the 3D-printing group (P<.001), and operative mortality, permanent stroke, permanent SCD, and the composite outcome occurred in 7 (9.1%), 9 (11.7%), 8 (10.4%), and 19 (24.7%), respectively. Open repairs of extensive TAAA with 3D printing showed favorable safety and efficacy, which need further validation by larger studies.

Current approaches to spinal cord protection during open thoracoabdominal aortic aneurysm repair.

Current approaches to spinal cord protection during open thoracoabdominal aortic aneurysm repair.

Practice of neuromonitoring in open and endovascular thoracoabdominal aortic repair-an international expert-based modified Delphi consensus study.

Spinal cord injury is detrimental for patients undergoing open or endovascular thoracoabdominal aortic aneurysm (TAAA) repair. The aim of this survey and of the modified Delphi consensus was to gather information on current practices and standards in neuroprotection in patients undergoing open and endovascular TAAA. The Aortic Association conducted an international online survey on neuromonitoring in open and endovascular TAAA repair. In a first round an expert panel put together a survey on different aspects of neuromonitoring. Based on the answers from the first round of the survey, 18 Delphi consensus questions were formulated. A total of 56 physicians completed the survey. Of these, 45 perform open and endovascular TAAA repair, 3 do open TAAA repair and 8 do endovascular TAAA repair. At least 1 neuromonitoring or protection modality is utilized during open TAAA surgery. Cerebrospinal fluid (CSF) drainage was used in 97.9%, near infrared spectroscopy in 70.8% and motor evoked potentials or somatosensory evoked potentials in 60.4%. Three of 53 centres do not utilize any form of neuromonitoring or protection during endovascular TAAA repair: 92.5% use CSF drainage; 35.8%, cerebral or paravertebral near infrared spectroscopy; and 24.5% motor evoked potentials or somatosensory evoked potentials. The utilization of CSF drainage and neuromonitoring varies depending on the extent of the TAAA repair. The results of this survey and of the Delphi consensus show that there is broad consensus on the importance of protecting the spinal cord to avoid spinal cord injury in patients undergoing open TAAA repair. Those measures are less frequently utilized in patients undergoing endovascular TAAA repair but should be considered, especially in patients who require extensive coverage of the thoracoabdominal aorta.

Management of Visceral Artery Patch Aneurysms and Segmental Artery Patch Aneurysms Following Open Thoracoabdominal Aortic Aneurysm Repair

Segmental intercostal/lumbar and visceral arteries are often reimplanted as a patch with surrounding native aortic tissue during open thoracoabdominal aortic aneurysm (TAAA) repair to preserve perfusion of the spinal cord and expedite visceral revascularization. However, late aneurysmal degeneration of the aortic tissue in the patch is a known, albeit infrequent, complication of this technique. The objective of this study was to describe our experience with management of visceral artery patch (VAP) aneurysms and segmental artery patch (SAP) aneurysms following TAAA repair. We retrospectively identified 57 patients (median age, 62 years; range, 50-73 years) who underwent VAP aneurysm and/or SAP aneurysm repair in our single practice (1986-2021). Median time from initial TAAA repair to patch aneurysm repair was 9 years (range, 5-12 years). Of these 57 repairs, 37 were for VAP aneurysm, 13 were for SAP aneurysm, and 7 were for both (Table). All 37 VAP aneurysms were repaired with open TAAA reoperations, while SAP aneurysms were addressed with either open repair (n = 13) or endovascular exclusion with thoracic aortic endografts (n = 7). Twenty-three patients (40%) had heritable thoracic aortic disease, of whom 17 had Marfan syndrome (30%). Crawford extent II repair was the most common preceding TAAA repair (n = 35, 61%). Patients presenting with patch aneurysm were often symptomatic (n = 41; 72%). Additionally, eight patients (14%) presented with patch aneurysm rupture. Early outcomes included operative mortality and adverse event, a composite variable comprised of operative death or persistent renal failure necessitating dialysis, paraplegia, paraparesis, or stroke. Operative mortality was 9% (n = 5); however, no operative deaths occurred in those treated with endovascular repair. The adverse event rate was 11% (n = 6), including four patients (7%) who developed persistent renal failure requiring dialysis following their repair. Only one patient (2%) experienced a stroke postoperatively. No patients experienced persistent paraplegia, including those who had endograft coverage of their intercostal patch without intercostal revascularization. Of 13 open SAP aneurysm repairs, 7 were performed with subsequent intercostal artery reimplantation. Left heart bypass was not used in any repairs; however, other adjuncts such as cerebrospinal fluid drainage (n = 27; 47%) and cold renal perfusion (n = 38; 67%) were used frequently. Most patients were discharged home (n = 49; 86%) (median length of hospital stay, 10 days; range, 9-14 days). Reoperative open VAP and SAP aneurysm repair is technically challenging; however, it can be performed with reasonable outcomes. Isolated SAP aneurysms can be safely managed with endovascular exclusion with promising results.TablePreoperative characteristics, operative details, and early outcomes in 57 visceral artery patch (VAP) aneurysm and segmental artery patch (SAP) aneurysm repairsVariablePatch aneurysm (n = 57)Age, years62 [50-73]Male sex30 (53)Time from initial TAAA repair to patch aneurysm repair, years9 [5-12]Heritable thoracic aortic disease23 (40)Tobacco use39 (68)Symptomatic41 (72)Rupture8 (14)Prior extent II repair35 (61)Urgent or emergency repair13 (23)Pseudoaneurysm at site of patch aneurysm15 (26)Open repaira50 (88) VAP aneurysm only37 (74) SAP aneurysm only6 (12) Both7 (14)Endovascular repair7 (12) VAP aneurysm0 SAP aneurysm7 (100)Cerebrospinal fluid drainage27 (47)Left heart bypass0Adverse event6 (11)Operative death5 (9)Persistent paraplegia0Persistent renal failure4 (7)Length of intensive care unit stay, days4 [3-6]Length of hospital stay, days10 [9-14]Discharged home49 (86)Values are number (%) or median (quartile 1-quartile3 [Q1-Q3]). Variables with missing data are clarified by available sample size.aPercentages in the open and endovascular repair subgroups are expressed as percentage of total open or endovascular repairs, respectively. Seven open repairs were performed in patients who had both VAP and SAP aneurysms repaired simultaneously. Open table in a new tab

Mid-term Outcomes of Open Thoracoabdominal Aortic Aneurysm Repair Following Thoracic Endovascular Aortic Repair

The aim of this study was to evaluate the safety and durability of open repair in patients with thoracoabdominal aortic aneurysm (TAAA) after thoracic endovascular aortic repair (TEVAR). Data were analyzed for 65 patients (20 men; 30.8%) undergoing open TAAA repair (TAAAR) at a median of 2.6 years after TEVAR. Outcomes were compared between patients with and without Marfan syndrome (MFS) (n = 39; 60%). Mean age at TAAAR was 41 ± 11 years. Before TAAAR, 27 patients (41.5%) underwent re-TEVAR. Type I endoleak was seen in 21 patients (32.3%), type II endoleak in 4 (6.2%), patent false lumen in 38 (58.5%), aortic rupture in 10 (15.4%), and graft infection in 2 (3.1%). TAAAs were Crawford extent I in 10 (15.4%), II in 23 (35.4%), III in 23 (35.4%), and IV in 9 (13.8%). Maximal TAA size was 72 ± 22 mm (Table). Emergent TAAAR was done in 11 (16.9%). Femoro-femoral bypass was used in 36 (55.4%) and circulatory arrest in 23 (35.4%). Endograft was explanted in 33 (50.8%). Stroke, paraplegia, and acute kidney injury occurred in five (7.7%), seven (10.8%), and seven (10.8%) patients, respectively. Operative mortality was 16.9% (11/65), due to stroke (n = 5), respiratory failure (n = 2), bowel necrosis (n = 1), low cardiac output (n = 1), and coagulopathy (n = 2). Endograft extraction was predictive of operative death (odds ratio, 5.63; 95% confidence interval, 1.11-28.52; P = .037). Clinical and computed tomography follow-up was complete in 100% (54/54) at a mean of 3.1 ± 1.4 years. Branch vessel events occurred in 11 patients at a median of 10 months (range, 0.4-18.3), including intercostal atrial (IA) dilation in six, IA stenosis in three, and iliac stenosis in one, exclusively seen in MFS (32.4% [11/34] vs 0; P = .004). Aortic graft infection occurred in two patients at 0.4 and 3.7 years, respectively; one died and one survived after medical therapy. Ascending aortic + total arch repair was done for retrograde type A dissection in two patients at 2.5 and 1.3 years, respectively. Late death occurred in four patients at 1.9 ± 1.7 years from aortotracheal fistula in two, and sepsis and stroke in one each. At 5 years, survival and freedom from reoperation were 73.6% and 95.7%, respectively, which did not differ significantly between MFS and non-MFS patients (P = .084 and P = .465, respectively). In this series of thoracoabdominal aortic aneurysm after TEVAR, open repair was safe and achieved favorable early and midterm outcomes. Endograft extraction predicted early mortality risk. Although not at increased risk of mortality and late reoperation, patients with MFS are prone to developing branch vessel dilation/stenosis early after open TAAAR.TablePatient profile, operative data, and late outcomes of thoracoabdominal aortic aneurysm repair (TAAAR) after thoracic endovascular aneurysm repair (TEVAR)VariableWhole series (n = 65)MFSP valueYes (n = 39)No (n = 26)Baseline characteristics Age, years41 ± 1134 ± 752 ± 8<.001 Male gender20 (30.8)18 (46.2)2 (7.7).001 Body mass index >25 kg/m221 (32.3)8 (20.5)13 (50).017 Hypertension34 (52.3)11 (28.2)23 (88.5).000 Smoking23 (35.4)8 (20.5)15 (57.7).003 Indications for prior TEVAR.001Type B aortic dissection43 (66.2)23 (59)20 (76.9)Type A aortic dissection18 (27.7)16 (41)2 (7.7)Penetrating aortic ulcer3 (4.6)0 (0)3 (11.5)Aortic rupture1 (1.5)0 (0)1 (3.8) Maximal proximal aortic size, mm30 ± 529 ± 431 ± 5.110 Maximal distal aortic size, mm72 ± 2266 ± 1580 ± 27.014Operative data Emergency repair11 (16.9)2 (5.1)9 (34.6).005 Distal perfusion strategy.019Simple aortic clamping9 (13.8)4 (10.3)5 (19.2).465Aorto-iliac bypass20 (30.8)17 (43.6)3 (11.5).007Femoro-femoral bypass36 (55.4)18 (46.2)18 (69.2).080Deep hypothermic circulatory arrest23 (35.4)9 (23.1)14 (53.8).017 Part or complete graft extraction33 (50.8)15 (38.5)18 (69.2).023 Clamp and ischemic times, minutesProximal aortic clamp time16 (0-21)17 (12-26)0 (0-17.5).026Intercostal artery38 (23-59)38 (21-57)39 (27-69).558Superior mesenteric artery33 (24-43)36 (24-45)28 (24-36).098Celiac artery, unprotected40 (30-57)45 (35-59)31 (25-39).006Maximal renal artery44 (35-52)45 (40-55)37.5 (28-46).008 Intercostal/lumbar artery reattachment52 (80)34 (87.2)18 (69.2).114 Reconstruction of subclavian artery15 (23.1)9 (23.1)6 (23.1)1.000 Reconstruction of right iliac artery37 (57.8)24 (61.5)13 (52).604 Cerebrospinal fluid drainage45 (69.2)31 (79.5)14 (53.8).053Early outcomes Operative mortality11 (16.9)5 (12.8)6 (23.1).325 Stroke5 (7.7)2 (5.1)3 (11.5).382 Paraplegia7 (10.8)2 (5.1)5 (19.2).106 Reoperation for bleeding8 (10.8)5 (11.6)3 (9.7)1.000 Acute kidney injury requiring dialysis7 (10.8)3 (7.7)4 (15.4).424 Pulmonary complications19 (29.2)7 (17.9)12 (46.2).025 Gastrointestinal dysfunction4 (6.2)2 (5.1)2 (7.7)1.000 Length of intensive care unit stay, days3.7 (1.7-5.6)3.5 (1.6-5.3)4.3 (2.4-7.1).090Late outcomes(n = 54, %)(n = 34, %)(n = 20, %) Follow-up duration, years3.1 ± 1.43.3 ± 1.32.7 ± 1.5.275 Late death4 (7.4)1 (2.9)3 (15).138 Late reoperation2 (3.7)2 (5.9)0 (0).525 Branch vessel dilation or stenosisa11 (20.4)11 (32.4)0 (0).004 5-year Kaplan-Meier survival, %73.6 (58.9-83.8)81.0 (59.7-91.7)61.5 (37.2-78.8).084 5-year freedom from reoperation, %95.7 (72.9-99.4)93.3 (61.3-99.0)100 (100).465MFS, Marfan syndrome; TAAAR, thoracoabdominal aortic aneurysm repair; TEVAR, thoracic endovascular aortic repair.Data are presented as mean ± standard deviation, median (interquartile range), number (%), or % (95% confidence interval).aRefers to aneurysmal dilation or stenosis (or occlusion) in abdominal aortic branches and the iliac arteries. 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Integrative respiratory support during thoracoabdominal aortic aneurysm repair in a patient with severe lung disease: a case report

BackgroundThoracoabdominal aneurysm repair is a highly complicated procedure, especially among patients with severe lung disease, resulting in respiratory problems during and after the surgery. Herein, we designed a novel intraoperative respiratory support to address this.Case presentationAn open thoracoabdominal aortic aneurysm repair was performed on a 65-year-old man who had severe chronic obstructive pulmonary disease with a giant right lung bulla. One-and-a-half lung ventilation by left lower lobe blockade was maintained during the operation to avoid right barotrauma. Cardiopulmonary bypass (CPB) was established with venous cannulas in the right internal jugular vein and left femoral vein for elective venovenous extracorporeal membrane oxygenation (VV-ECMO). After aortic repair and withdrawal from CPB, the VV-ECMO was consecutively initiated using the same circuit by connecting the arterial cannula to the right internal jugular venous cannula. The patient maintained adequate oxygenation during hemostasis under the support of VV-ECMO after protamine was administered. He was weaned from VV-ECMO in the operating room and discharged without any complications.ConclusionPartial bronchial blockage and intraoperative VV-ECMO using the same circuit of CPB were useful methods for severe lung disease during a thoracoabdominal aortic repair.

Risk profile and operative outcomes in patients with and without Marfan syndrome undergoing thoracoabdominal aortic aneurysm repair

ObjectivesTo compare operative and long-term outcomes between patients with and without Marfan syndrome undergoing thoracoabdominal aortic aneurysm repair. MethodsWe identified all consecutive patients undergoing thoracoabdominal aortic aneurysm repair between 1997 and 2022. Primary outcome was composite of major adverse events. Secondary outcomes were individual complications and long-term survival. Inverse probability of treatment weighting was performed. Weighted Kaplan-Meier curves were used to estimate long-term survival. Multivariable analysis identified factors associated with major adverse events. ResultsSix hundred eighty-four patients underwent open thoracoabdominal aortic aneurysm repair. Ninety (13.1%) had Marfan syndrome, whereas 594 (86.9%) did not. Marfan patients were younger (46 years [range, 36-56 years] vs 69 years [range, 61-76 years]; P < .001). Extent II or III aneurysms (57 out of 90 [63.3%] vs 211 out of 594 [35.6%]; P < .001) and type I or III chronic dissection (77 out of 90 [85.3%] vs 242 out of 594 [40.8%]; P < .001) were more common. Cardiovascular risk factors were less frequent in Marfan patients. There was no difference in major adverse events between groups (12 out of 90 [13.3%] vs 100 out of 594 [16.8%]; P = .49). Operative mortality was similar between groups (3 out of 90 [3.3%] vs 28 out of 594 [4.7%]; P = .75). Unweighted survival at 10 years was 78.7% vs 46.8% (P = .001). Weighted Kaplan-Meier curves showed no difference in long-term survival (adjusted hazard ratio, 0.79; 95% CI, 0.32-1.99; P = .62; Log-rank P = .12). At multivariable analysis, renal insufficiency (odds ratio, 2.29; 95% CI, 1.43-3.68; P < .01) and urgent/emergency procedure (odds ratio, 2.17; 95% CI, 1.35-3.48; P < .01) were associated with major adverse events, whereas Marfan syndrome was not (odds ratio, 1.56; 95% CI, 0.69-3.49; P = .28). ConclusionsOpen thoracoabdominal aortic aneurysm repair can be performed with similar operative outcomes in patients with and without Marfan syndrome despite differing risk profiles. Operative/perioperative strategies must be tailored to specific needs of each patient to optimize outcomes.