Extensive Thoracoabdominal Aortic Aneurysm Repair Research Articles

Long-term outcomes of extensive thoracoabdominal aortic aneurysm repair utilizing normothermic iliac perfusion: A retrospective cohort study with 10-year single-center experience.

Normothermic iliac perfusion has been increasingly utilized for TAAA repair; however, the long-term outcomes in large samples are lacking. This study was designed to assesses the perioperative and long-term results of thoracoabdominal aortic repair using normothermic iliac perfusion. We retrospectively analyzed 156 patients having Crawford extent II or III thoracoabdominal aortic aneurysm replacement with normothermic iliac perfusion from 2012 to 2022. Primary endpoints were composite adverse events and long-term survival, which encompassed 30-day mortality, persistent stroke, persistent paraplegia, and acute renal failure needing continuous dialysis. The cohort was divided into two subgroups based on the use of selective visceral and cold renal perfusion techniques. The combined adverse event rate was 14.1%. Specific rates were: 30-day mortality (4.5%), persistent stroke (1.9%), persistent paraplegia (4.5%), and renal failure requiring persistent dialysis (3.2%). The median follow-up time was 67 months. Overall survival rates at 1, 3, 5, 7, and 10 years were 91.6%, 90.0%, 85.4%, 77.6%, and 69.7%, respectively. Subgroup analysis showed the visceral and renal perfusion group had a significantly reduced adverse event incidence compared to the nonperfusion group (6.5% vs. 19.1%, P=0.026). Multivariable logistic regression analysis confirmed selective visceral and cold renal perfusion techniques as protective factors against postoperative adverse events (OR 0.30, 95%CI 0.09-0.94; P=0.038). Multivariable Cox regression analysis identified age ≥50 years (HR 2.63, 95%CI 1.10-6.27; P=0.029) and NYHA grade ≥III (HR: 3.20, 95% CI: 1.04-9.87; P=0.043) as independent risk factors predicting overall survival. Normothermic iliac perfusion is a feasible option for thoracoabdominal aortic repair with cost benefits and simpler management, and selective visceral and cold renal perfusion techniques may further improve its safety and effectiveness. However, enhanced vigilance and meticulous care are essential, particularly for elderly patients and those with cardiac insufficiency.

Collateral network concept in 2023.

Extensive thoracoabdominal aortic aneurysm repair can cause spinal cord ischemia which significantly impacts survival and quality of life. Although this complication is uncommon, it is important to recognize the pathophysiology and preventative measures. In the 1990s, Dr. Griepp and colleagues proposed the existence of an extensive collateral network that supports spinal cord perfusion, "the collateral network concept". This includes an interconnecting complex of vessels in the intraspinal, paraspinous, and epidural spaces, and in the paravertebral muscles, involving the intercostal and lumbar segmental arteries as well as the subclavian and hypogastric (iliac) arteries. In this concept, as opposed to the one major segmental input model such as the Adamkiewicz artery, recognition of the importance of multiple inputs to the spinal circulation is paramount to maintaining the spinal blood flow and preventing spinal cord ischemia. In this article, we review the current evidence of the collateral concept and its application in aortic surgery.

Intercostal Artery Reconstruction: The Simple and Effective Technique on Spinal Cord Protection during Thoracoabdominal Aortic Replacement

To retrospectively analyze the role of intercostal artery reconstruction in the spinal cord protection for patients undergoing extensive thoracoabdominal aortic aneurysm repair. From August 2007 to 2014, thoracoabdominal aortas (Crawford II) of 81 consecutive patients with mean age 39.4 ± 10.32years were repaired. Seventy-three of these patients (90.12%) were diagnosed with aortic dissection in our group, 25 (30.86%) with Stanford type A dissection and 48 (59.26%) with Stanford B aortic dissection. All 25 patients with type A dissection have previously undergone surgical procedures which include Bentall's procedures in 11 cases, ascending aortic replacement in 6 cases, and total aortic arch replacement in 8 cases. All procedures were performed under profound hypothermia with interval cardiac arrest after making a thoracoabdominal incision. Extracorporeal circulation was instituted with 2 arterial cannulae and a single venous cannula in the right atrium. T6-T12 intercostal arteries and L1 and L2 lumbar arteries were formed to a neo-intercostal artery in place and were connected to an 8mm branch for maintaining spinal cord blood perfusion. Visceral arteries were joined into a patch and anastomosed to the end of the main graft. The left renal artery was anastomosed to an 8mm branch or joined to the patch. The other 10mm branches were anastomosed to iliac arteries. With 100% follow-up, early mortality was 7.4%. Six deaths were recorded; 1 patient died of cerebral hemorrhage, 3 of renal failure, 1 of heart failure because of myocardial infarction, and the last one died from the rupture of celiac artery dissection. The rate of postoperative spinal cord deficits was 3.7%, 2 patients with paraplegia and 1 patient with paraparesis. None had bladder or rectum dysfunction. Neo-intercostal arteries were clogged in 12 patients within follow-up period and formed pseudoaneurysm in 2 patients with Marfan syndrome. The mean survival time in this group was 54.22 ± 3.03months (95% confidence interval 44.37-59.90months) with survival rate of 92.37% after 1year, 89.02% after 2years, and 85.54% after 5years. All patients were free from spinal cord deficits. Intercostal artery reconstruction is an effective technique for spinal cord protection in patients with the thoracoabdominal aortic repair. It can achieve favorable results and avoid spinal cord deficits with long-term follow-up.

Contemporary outcomes of open thoracoabdominal aortic aneurysm repair in octogenarians

We sought to evaluate our contemporary outcomes with open thoracoabdominal aortic aneurysm (TAAA) repair in octogenarians to determine whether open TAAA repair is a viable option, with acceptable risk, in this elderly cohort. We analyzed clinical data from 1267 enrolled patients who underwent open TAAA repair between 2003 and 2013. Eighty-eight patients (7%) were octogenarians (median age, 82 years; range, 80-92 years) and 1179 were 79 years of age or less. Aneurysm rupture was more common in octogenarians (14% vs 4.7%, P=.001), whereas aortic dissections predominated in younger patients (43.9% vs 13%, P<.001). Octogenarians had higher rates of visceral-branch endarterectomy/stenting (58% vs 33.5%, P<.001), adverse postoperative outcomes (36% vs 15.3%, P<.001), operative mortality (26% vs 6.9%, P<.001), and prolonged hospital stay (P=.004). Among octogenarians, preoperative aortic dissection was most commonly associated with extent I repair (42% vs <10% for other extents, P<.001). Extent II repairs most frequently necessitated concomitant visceral-branch procedures and carried the highest risk of mortality (62%). Extent I and III repairs carried intermediate operative risk, and extent IV repairs posed the least risk (11%). Multivariate modeling analysis identified extent II TAAA (P=.001; odds ratio, 11.6), presence of concomitant dissection (P=.02; odds ratio, 5.6), and aneurysm rupture (P=.02; odds ratio, 5.7) as independent predictors of operative mortality in octogenarians. Open extent II TAAA repair carries significant risk for octogenarians; extent I, III, and IV repairs incur more reasonable postoperative risk. Although TAAA repair should not be denied to octogenarians based solely on age, extensive TAAA repair should be performed with caution.

Continued favorable results with open surgical repair of type IV thoracoabdominal aortic aneurysms

Type IV thoracoabdominal aortic aneurysm (TAAA) repair, despite low risk of spinal cord ischemia (SCI), is reported to have significant morbidity and mortality. This has led some to apply adjuncts (eg, extracorporeal circulation) used in more extensive TAAA repair or to consider alternative approaches, such as hybrid operations. We have used a consistent, simplified surgical approach to type IV TAAA, and the goal of the present study is to review experience over 2 decades with such treatment and to identify correlates of surgical morbidity. All type IV repairs at Massachusetts General Hospital from January 1989 through September 2009 were evaluated for clinical features, technical operative details, and 30-day outcomes. Logistic regression identified predictors of morbidity. Survival was assessed using Kaplan-Meier analysis. A total of 179 patients underwent type IV repair, with elective repair in 156 (87%) and urgent in 23 (13%). The clamp-and-sew technique was used for all operations, with routine hypothermic renal perfusion. Clinical features were age 73 ± 8 years, coronary artery disease in 89 (50%), and creatinine level >1.8 mg/dL defining chronic renal insufficiency (CRI) in 32 (18%). Operative reconstruction in 166 (93%) consisted of one beveled proximal anastomosis incorporating the descending thoracic aorta, celiac, superior mesenteric artery, and right renal arteries origins (mean visceral clamp time, 36 ± 12 minutes) and a side-arm graft to the left renal artery. Technical details included previous abdominal aortic aneurysm (AAA) repair in 52 (29%), operative time of 290 ± 90 min, estimated blood loss of 2.7 ± 1.4 L, and splenectomy in 57 (32%). The 30-day outcomes were death in 5 (2.8%), myocardial infarction in 6 (3.4%), hemodialysis in 5 (2.8%), and any degree of SCI in 4 (2.2%). Regression analysis identified a history of CRI as an independent predictor of postoperative complication or death (odds ratio, 3.4; 95% confidence interval, 1.4-8). Survival rates at 1, 5, and 10 years were 89% ± 2%, 62% ± 4%, and 36% ± 5%, respectively. A simplified operative approach for type IV TAAA repair is associated with favorable perioperative results. These data refute the need for surgical adjuncts commonly applied in more extensive TAAA and indicate that the hybrid operation is an illogical posture. CRI should figure prominently in clinical decision making. Long-term survival equates that observed after routine AAA repair.

Staged repair significantly reduces paraplegia rate after extensive thoracoabdominal aortic aneurysm repair

Paraplegia remains a devastating, and still too frequent, complication after repair of extensive thoracoabdominal aortic aneurysms. Strategies to prevent ischemic spinal cord damage after extensive segmental artery sacrifice-or occlusion, essential for endovascular repair-are still evolving. Ninety patients who underwent extensive segmental artery sacrifice (median, 13; range, 9-15) during open surgical repair from June 1994 to December 2007 were reviewed retrospectively. Fifty-five patients (mean age, 65 +/- 12 years; 49% were male), most with extensive Crawford type II thoracoabdominal aortic aneurysms, had a single procedure (single-stage group). Thirty-five patients (mean age, 62 +/- 14 years; 57% were male) had 2 procedures (2-stage group), usually Crawford type III or IV repair after operation for Crawford type I descending thoracic aneurysm. The median interval between the 2-stage procedures was 5 years (3 months to 17 years). There were no significant differences between the groups with regard to age, gender, cause of the aneurysm, hypertension, chronic obstructive pulmonary disease, urgency, previous cerebrovascular accidents, year of procedure, or cerebrospinal fluid drainage. In single-stage procedures, hypothermic circulatory arrest was used in 29% of patients, left-sided heart bypass was used in 40% of patients, and partial cardiopulmonary bypass was used in 27% of patients. Somatosensory-evoked potentials were monitored in all patients, and motor-evoked potentials were monitored in 39% of patients. Cerebrospinal fluid was drained in 84% of patients. Overall hospital mortality was 11.1%. There were no significant differences in mortality, stroke, postoperative bleeding, infection, renal failure, or pulmonary insufficiency between the groups. However, 15% of patients in the single-stage group had permanent spinal cord injury versus none in the 2-stage group (P = .02). The significantly lower rate of paraplegia and paraparesis in the 2-stage group occurred despite a significantly higher number of segmental arteries sacrificed in this group: a median of 14 (11-15) versus 12 (9-15) (P < .0001). A staged approach to extensive thoracoabdominal aortic aneurysm repair may reduce the incidence of spinal cord injury. This is of particular importance in designing strategies involving hybrid or entirely endovascular procedures.

Staged repair significantly reduces paraplegia rate after extensive thoracoabdominal aortic aneurysm repair

Staged repair significantly reduces paraplegia rate after extensive thoracoabdominal aortic aneurysm repair

Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: Results of a randomized clinical trial

Objective: Despite the use of various strategies for the prevention of spinal cord ischemia, paraplegia and paraparesis continue to occur after thoracoabdominal aortic aneurysm (TAAA) repair. Although cerebrospinal fluid drainage (CSFD) is often used as an adjunct for spinal cord protection, its benefit remains unproven. The purpose of this randomized clinical trial was to evaluate the impact of CSFD on the incidence of spinal cord injury after extensive TAAA repair. Methods: After randomization, 145 patients underwent extent I or II TAAA repairs with a consistent strategy of moderate heparinization, permissive mild hypothermia, left heart bypass, and reattachment of patent critical intercostal arteries. The repairs were performed with CSFD (n = 76) or without CSFD (n = 69). In the former group, CSFD was initiated during the operation and continued for 48 hours after surgery. The target CSF pressure was 10 mm Hg or less. Results: The two groups had similar risk factors for paraplegia. Aortic clamp time, left heart bypass time, and number of reattached intercostal arteries were also similar in both groups. Thirty-day mortality rates were 5.3% (four patients) and 2.9% (two patients) for CSFD and control groups, respectively (P =.68). Nine patients (13.0%) in the control group had paraplegia or paraparesis develop. In contrast, only two patients in the CSFD group (2.6%) had deficits develop (P =.03). No patients with CSFD had immediate paraplegia. Overall, CSFD resulted in an 80% reduction in the relative risk of postoperative deficits. Conclusion: Perioperative CSFD reduces the rate of paraplegia after repair of extent I and II TAAAs. (J Vasc Surg 2002;35;631-9.)

Renal perfusion during thoracoabdominal aortic surgery: cold crystalloid is superior to normothermic blood

Introduction. Renal failure remains a significant and potentially lethal complication after thoracoabdominal aortic aneurysm (TAAA) repair, ranging from 7% to 40% in recent series. The purpose of this randomized trial was to compare two methods of selective renal perfusion (cold crystalloid vs normothermic blood) during TAAA repair.Methods. Thirty randomized patients undergoing TAAA repair with left heart bypass (LHB) had renal artery perfusion with either 4°C lactated Ringer’s solution (14 patients) or normothermic blood from the bypass circuit (16 patients). Acute renal dysfunction was defined as an elevation in serum creatinine level exceeding 50% of baseline within 10 postoperative days.Results. One death occurred in each group. One patient in the blood perfusion group developed kidney failure requiring hemodialysis. Ten patients (63%) in the blood perfusion group and 3 patients (21%) in the cold crystalloid perfusion group developed acute renal dysfunction (p = 0.03). Multivariable analysis confirmed that the use of cold crystalloid perfusion was independently protective against acute renal dysfunction (p = 0.02, odds ratio 0.133).Conclusions. When using LHB during repair of extensive TAAAs, selective cold crystalloid perfusion offers superior renal protection when compared with normothermic blood perfusion. Introduction. Renal failure remains a significant and potentially lethal complication after thoracoabdominal aortic aneurysm (TAAA) repair, ranging from 7% to 40% in recent series. The purpose of this randomized trial was to compare two methods of selective renal perfusion (cold crystalloid vs normothermic blood) during TAAA repair. Methods. Thirty randomized patients undergoing TAAA repair with left heart bypass (LHB) had renal artery perfusion with either 4°C lactated Ringer’s solution (14 patients) or normothermic blood from the bypass circuit (16 patients). Acute renal dysfunction was defined as an elevation in serum creatinine level exceeding 50% of baseline within 10 postoperative days. Results. One death occurred in each group. One patient in the blood perfusion group developed kidney failure requiring hemodialysis. Ten patients (63%) in the blood perfusion group and 3 patients (21%) in the cold crystalloid perfusion group developed acute renal dysfunction (p = 0.03). Multivariable analysis confirmed that the use of cold crystalloid perfusion was independently protective against acute renal dysfunction (p = 0.02, odds ratio 0.133). Conclusions. When using LHB during repair of extensive TAAAs, selective cold crystalloid perfusion offers superior renal protection when compared with normothermic blood perfusion.

Left heart bypass reduces paraplegia rates after thoracoabdominal aortic aneurysm repair

Background. The optimal strategy for spinal cord protection during thoracoabdominal aortic aneurysm (TAAA) repair remains unclear. We evaluated the protective effect of left heart bypass (LHB) during repair of extensive TAAAs. Methods. During a 12-year period, 710 patients had repair of extent I or II TAAAs. Left heart bypass was used in 312 (43.9%) patients. This group was retrospectively compared with 398 (56.1%) patients who had operations without LHB. Results. The overall 30-day survival rate was 94.8% (673 patients). In 42 patients, (6.0%) paraplegia or paraparesis developed. In patients with extent I TAAAs, paraplegia and paraparesis rates in LHB (6 of 123, 4.9%) and non-LHB (9 of 246, 3.7%) groups were similar ( p = 0.576) despite longer aortic clamp times in the former group. In patients with extent II TAAAs, the LHB group had a lower incidence of paraplegia or paraparesis (9 of 189, 4.8%) compared with the non-LHB group (18 of 137, 13.1%; p = 0.007). Conclusions. Left heart bypass reduced the risk of paraplegia and paraparesis in patients who had repair of extent I and II TAAAs.