Outcomes Of Open Surgical Repair Research Articles

Results of open surgical repair of acute types III and IV acromioclavicular joint dislocation using the tightrope

Background Acromioclavicular joint dislocation presents a difficult challenge in controlling the stresses on the clavicle during the recovery period and hampers early mobilization of the shoulder joint. We have chosen a new modality for fixation types III and IV and compared its results with other methods of fixation. Patients and methods Between 2008 and 2011, 13 cases of acute acromioclavicular joint dislocations were treated at our facilities using the Arthrex tightrope for restoring attachment of the clavicle to the coracoid process. The study group included 10 male and three female patients, with an average age of 34.2 years. The average duration between the injury and surgical fixation was 6.3 days. All patients had an MRI scan performed before surgical intervention for assessment of the coracoclavicular ligaments. Patients were evaluated at the end of 6 months after surgical reconstruction using the Constant Shoulder Scoring System. Results At the end of the follow-up period, there were only three failure cases and 10 of our 13 patients (76.9%) were adequately satisfied with the outcome. Conclusion Tightrope fixation is a very safe modality for fixation of acromioclavicular dislocations that restores anatomy and allows for early mobilization of the shoulder joint.

Results of Open Surgical Repair of Chronic Juxtarenal Aortic Occlusion.

Purpose:The aim of study was to review the results of open surgical repair (OSR) of chronic juxtarenal aortic occlusion (JRAO).Materials and Methods:We retrospectively reviewed the results of OSR performed in 47 patients (male, 92%; mean age, 59.9±9.3 years [range, 44–79]) with chronic JRAO during the past 21 years. In order to reduce intraoperative renal ischemic time (RIT), we excised a portion of the occluded segment of the infrarenal aorta without proximal aortic clamping. We then performed suprarenal aortic clamping with both renal arteries clamped, removed the proximal aortic thrombus cap, confirmed both renal artery orifices, and moved the suprarenal aortic clamp to the infrarenal aorta to allow renal perfusion and standard aortoiliac reconstruction. We investigated early (<30 days) postoperative surgical morbidity (particularly renal function), operative mortality, and longterm patient survival. We conducted risk factor analysis for postoperative renal insufficiency.Results:The mean intraoperative RIT was 10.7±5.5 minutes (range, 3–25), including 6 patients who underwent concomitant pararenal aortic thromboendarterectomy. Postoperatively, five (11%) patients had transient renal insufficiency, one had pneumonia, and one patient had an acute myocardial infarction. However, there was no operative mortality or newly developed dialysis-dependent renal failure. Postoperative follow up was available in 36 (77%) patients for a mean period of 6.3 years (range, 1 month-17 years). Kaplan Meier calculations of patient survival at 5 and 10 years after surgery were 91.2% and 83.6%, respectively.Conclusion:We have experienced short RIT, acceptable early postoperative results and long-term survival after OSR of chronic JRAO.

Outcomes of open surgical repair of descending thoracic aortic disease.

BackgroundTo determine the predictors of clinical outcomes following surgical descending thoracic aortic (DTA) repair.MethodsWe identified 103 patients (23 females; mean age, 64.1±12.3 years) who underwent DTA replacement from 1999 to 2011 using either deep hypothermic circulatory arrest (44%) or partial cardiopulmonary bypass (CPB, 56%).ResultsThe early mortality rate was 4.9% (n=5). Early major complications occurred in 21 patients (20.3%), which included newly required hemodialysis (9.7%), low cardiac output syndrome (6.8%), pneumonia (7.8%), stroke (6.8%), and multi-organ failure (3.9%). None experienced paraplegia. During a median follow-up of 56.3 months (inter-quartile range, 23.1 to 85.1 months), there were 17 late deaths and one aortic reoperation. Overall survival at 5 and 10 years was 80.9%±4.3% and 71.7%±5.9%, respectively. Reoperation-free survival at 5 and 10 years was 77.3%±4.8% and 70.2%±5.8%. Multivariable analysis revealed that age (hazard ratio [HR], 1.10; 95% confidence interval [CI], 1.05 to 1.15; p<0.001) and left ventricle (LV) function (HR, 0.88; 95% CI, 0.82 to 0.96; p<0.003) were significant and independent predictors of long-term mortality. CPB strategy, however, was not significantly related to mortality (p=0.49).ConclusionSurgical DTA repair was practicable in terms of acceptable perioperative mortality/morbidity as well as favorable long-term survival. Age and LV function were risk factors for long-term mortality, irrespective of the CPB strategy.

Outcomes of open surgical repair for chronic type B aortic dissections

Open surgical repair (OSR) for chronic type B aortic dissection (CTBAD) has an associated morbidity and mortality. The role of thoracic endovascular aortic repair (TEVAR) in CTBAD has not been determined. We analyzed our contemporary experience of CTBAD undergoing OSR to identify high-risk patients who may be considered for TEVAR. From 1999 to 2010, 221 patients had repair of descending thoracic and thoracoabdominal aortic aneurysms, including 86 patients with CTBADs. We analyzed this cohort for mortality, complications, length of stay, and reinterventions. OSR was performed in 25 (29%) and 61 (71%) patients for descending thoracic and thoracoabdominal CTBAD, respectively. Median age was 57.0 years (interquartile range [IQR], 52.0-64.2 years), and median diameter was 6.0 cm (IQR, 5.0-6.9 cm). Fifty-nine patients (69%) were male. Eight (9%) were treated for rupture. Follow-up duration was 4.6 years (IQR, 2.8-6.9 years). Hospital mortality occurred in five patients (5.8%). Cardiopulmonary bypass was used in 83 patients (97%) and deep hypothermic arrest in 36 (42%). Two patients (2.3%) each developed paraplegia, stroke, and renal failure requiring permanent hemodialysis in the postoperative period. Length of stay was 13.5 days (IQR, 10.0-21.0 days). Univariate predictors of hospital death included redo operations and prolonged pump time (P < .05). Six patients (7%) had aortic-related reoperations at 4.3 years (IQR, 2.7-5.2 years): one for an ascending aortic aneurysm and five for descending aortic aneurysms. Overall survival at 1, 5, and 7 years was 92%, 83%, and 70%, respectively, and freedom from reoperation was 99%, 90%, and 86%, respectively. OSR of CTBAD is a durable option with low mortality. Patients requiring redo operations or anticipated prolonged pump time need further evaluation to determine whether conventional OSR or TEVAR, if feasible, is the optimal treatment option.

Thoracic Aortic Aneurysms in Octogenarians: The Results of Open Surgical Repair Using Hypothermic Circulatory Arrest with Antegrade Selective Cerebral Perfusion

Although recent progress has expanded the indications for thoracic aortic surgery to include elderly patients, the procedure remains extremely invasive. We performed a chart review to determine the early and late outcomes of thoracic aortic surgery using hypothermic circulatory arrest (HCA) and antegrade selective cerebral perfusion (ASCP) in octogenarians. Of 79 patients who underwent surgery for thoracic aortic aneurysms from April 2007 through December 2012, 8 patients 80 years or older were selected for analysis. Mean age at the time of surgery was 84.3±1.39 years. The diagnoses were aortic dissection in 5 patients and degenerative thoracic aneurysm in 3 patients. All patients underwent surgery with HCA. The lowest body temperature was 25℃ ASCP was used as an additional brain-protection technique. Emergency operations were performed in 5 patients (62.5%). The mean duration of HCA was 60.4±19.7 minutes, that of aortic cross-clamping time was 143.0±30.4 minutes, and mean pump time was 207.8±44.4 minutes. The hospital mortality rate was 0%. Major postoperative complications occurred in 3 (37.5%) patients: stroke, temporary neurologic dysfunction, and paraparesis in 1 patient each. No patients required temporary dialysis for new-onset renal dysfunction. There were no deaths during the 65-month follow-up period. The early and late outcomes after thoracic aortic surgery at our hospital using HCA with ASCP in octogenarians are acceptable. The operations are performed with an acceptable operative risk, even under emergency situations, including acute aortic dissection.

Outcomes of Open Surgical Repair for Chronic Type B Aortic Dissections

Open surgical repair (OSR) for chronic type B aortic dissections (CTBAD) has an associated morbidity and mortality. The role of thoracic endovascular aneurysm repair (TEVAR) in CTBAD has not been determined. We analyzed our contemporary experience of CTBAD undergoing OSR to identify high-risk patients that may be considered for TEVAR. From 1999-2010, 221 patients had repair of descending thoracic and thoracoabdominal aortic aneurysms, including 86 patients with CTBAD. We analyzed this cohort for mortality, complications, length of stay, and reinterventions. OSR was performed in 25 (29%) and 61 (71%) patients for descending thoracic and thoracoabdominal CTBAD, respectively. Mean age was 58.4 years (±10.4) and mean diameter 6.2 cm (±1.1, 4.1-10.0). Fifty-nine (69%) patients were male. Eight (9%) were treated for rupture. Mean duration of follow-up was 5.2 years (±2.7). Hospital mortality occurred in five (5.8%) patients. Cardiopulmonary bypass was used in 83 (97%) and deep hypothermic arrest in 36 (42%) patients. Paraplegia occurred in two (2.3%), stroke in two (2.3%), and renal failure requiring permanent hemodialysis in two (2.3%) patients. Average length of stay was 19.6 days (±17.8). Univariate predictor of hospital mortality included redo-operations and prolonged pump time (P < .05). Maximum aneurysm diameter and rupture at presentation trended toward significance. Twenty (24.7%) patients of the 81 survivors died during follow-up (mean, 62.5 ± 36 months). Six patients (7%) had aortic related reoperations at a mean of 3.8 years (±1.8): one for ascending and five for descending aortic aneurysms. Overall survival at 1, 5, and 7 years was 92%, 83%, and 70%, respectively. Freedom from reoperation was 99%, 90%, and 86%, respectively. OSR of CTBAD is a durable option with low mortality. Patients requiring redo-operations or anticipated prolonged pump time need further evaluation to determine whether conventional OSR or TEVAR, if feasible, is the optimal treatment option.

Outcomes of Open Surgical Repair for Chronic Type B Aortic Dissections

Outcomes of Open Surgical Repair for Chronic Type B Aortic Dissections

Construct domain analysis of patient health-related quality of life: physical and mental trajectory profiles following open versus endovascular repair of abdominal aortic aneurysm

PurposeMany clinical trials comparing the outcomes of open surgical repair (OSR) versus endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs) have been conducted, with varying results. Surprisingly, few outcomes studies have closely examined perceived physical and mental health-related quality of life (HRQOL) factors through a validated survey tool. The purpose of this prospective observational study was to describe the trajectory of HRQOL measures, from baseline to 1 year after surgery, in patients undergoing OSR or EVAR for AAA, and to explore for differences in physical and mental composite scores and their construct domains (subscales) using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36®) tool.Patients and methodsOver an 18-month period, a small sample of patients undergoing elective AAA repair in a community hospital setting were prospectively enrolled. Fifteen patients undergoing OSR and twenty patients undergoing EVAR were studied. Physical and mental HRQOL parameters were assessed using the SF-36.ResultsNo significant differences in demographic and clinical variables were found between the OSR and EVAR groups. In the multivariable linear models with repeated measures, both groups showed a significant decline in physical health composite scores 30 days after the surgical procedure (P < 0.01). However, although the OSR group showed a statistically significant decline in three of the four physical health domains, the EVAR group declined in only one physical health domain. Only the OSR group showed a significant decline in three of the four mental health domains at 30 days; however, the decline of these domains was not reflected in the group’s mental health composite scores. By 90 days after surgery, both groups were not significantly different from their baseline in physical or mental health composite scores, or in any of their respective physical health domains.ConclusionIn this small sample of patients undergoing AAA repair, EVAR resulted in less physical and emotional decline than OSR in the early postoperative period. However, patients in both groups may return to near baseline status at 90 days.

Open Repair of Descending and Thoracoabdominal Aortic Aneurysms and Dissections in Patients Aged Younger Than 60 Years: Superior to Endovascular Repair?

The best option for repair of descending thoracic and thoracoabdominal aortic aneurysms (TAAA)-whether open operation or stent grafting-is increasingly a subject of controversy. We examined the results of open surgical repair in patients aged 60 years or younger to assess the value of conventional repair in younger patients. From October 2002 to October 2010, 107 of 294 TAAA operations were in patients (75 men [70%]) aged a mean of 48 ± 9 years. Twelve patients (11%) had Marfan syndrome. Operations were elective in 101 (94%); previous aortic operations had been performed in 40 (37%). The most common indication for operation was chronic dissection, in 60 (56%); 5 (4.7%) had acute dissection, and rupture was present in 6 (5.6%). Descending repair was undertaken in 44 (41%), in 32 (73%) as an elephant trunk stage II. Deep hypothermic circulatory arrest was used in 46 (42.9%). Neurologic monitoring and cerebrospinal fluid drainage were routine. Median postoperative follow-up was 4.3 years (range, 2 days to 7.9 years). Overall 30-day mortality was 4.7%. Stroke occurred in 4 patients (3.7%) and paraplegia in 1 (0.9%). The linearized rate for reoperation for TAAA was 0.22/100 patient-years (1 patient in 448.8 patient-years). Survival at 1, 5, and 8 years was 90.5%, 89.4% and 80.5%, respectively. During follow-up, 1 patient with Ehlers-Danlos died of aortic complications at 4.5 years. Although direct comparison with stent grafting is limited by the diversity of patients and indications in published reports, our results suggest that open repair should be the modality of choice. Early mortality and neurologic complication rates are similar, if not superior, to endovascular repair for descending aortic and TAAAs. Open repair has proven durability and a very low rate of required reintervention, in contrast with endovascular repair.

Treatment of failing vein grafts in patients who underwent lower extremity arterial bypass

PurposeWe attempted to determine risk factors for the development of failing vein graft and optimal treatment in patients with infrainguinal vein grafts.MethodsWe retrospectively reviewed a database of patients who underwent infrainguinal bypass using autogenous vein grafts due to chronic atherosclerotic arterial occlusive disease of lower extremity (LE) at a single institute between September 2003 and December 2011. After reviewing demographic, clinical, and angiographic features of the patients with failing grafts, we analyzed those variables to determine risk factors for the development of failing grafts. To determine an optimal treatment for the failing vein grafts, we compared results of open surgical repair (OSR), endovascular treatment (EVT) and conservative treatment.ResultsTwo hundred and fifty-eight LE arterial bypasses using autogenous vein grafts in 242 patients were included in this study. During the follow-up period of 39 ± 25 months (range, 1 to 89 months), we found 166 (64%) patent grafts with no restenosis, 41 (15.9%) failing grafts, 39 (15.1%) graft occlusions, and 12 (4.7%) grafts lost in follow-up. In risk factor analysis for the development of a failing graft, no independent risk factors were identified. After 50 treatments of the 41 failing grafts (24 OSR, 18 EVT, 8 conservative management), graft occlusion was significantly more common in conservative treatment group and severe (>75%) restenosis was significantly more common following EVT than OSR (P = 0.001). Reintervention-free graft patency was also superior in the OSR group to that of the EVT group (87% vs. 42%, P = 0.015).ConclusionOSR of failing grafts has better outcomes than EVT or conservative management in treating failing grafts.

Midterm Outcomes of Open Surgical Repair Compared with Thoracic Endovascular Repair for Isolated Descending Thoracic Aortic Disease

ObjectiveThis study aimed to assess the surgical morbidity and mortality of thoracic endovascular repair (TEVAR) as compared with open surgical repair (OSR) for isolated descending thoracic aortic disease.Materials and MethodsFrom January 1, 2006 through May 31, 2010, a total of 68 patients with isolated descending thoracic aortic disease were retrospectively reviewed for the presence of perioperative complication, 30-day mortality, and clinical success. The patients were divided into two groups (group 1, OSR, n = 40 vs. group 2, TEVAR, n = 28) and these groups were compared for major variables and late outcomes.ResultsThe mean age was 58 years (group I = 54 vs. group II = 63 years, p = 0.011). Significant perioperative complications occurred in 12 patients: 8 (20%) in group I and 4 (13%) in group II (p = 0.3). There were five 30 day mortalities of which 4 occurred in group I and 1 in group II (p = 0.23). Clinical success (effective aortic remodeling and complete false lumen obliteration or thrombosis) was achieved in 20 patients (71%). Mean Kaplan-Meier survival rate at 1 year was similar for both groups (group 1 = 87% vs. group 2 = 80%, p = 0.65).ConclusionThoracic endovascular repair for isolated thoracic aortic disease shows comparable results to OSR. However, the potential for endoleak or rupture remains a challenge that needs to be addressed in the future. Therefore, close follow-up study is needed for the evaluation of satisfactory long-term outcomes.

Open Surgical Repair of Thoracoabdominal Aortic Aneurysms

Despite much advancement in preoperative evaluation and perioperative care of patients with thoracoabdominal aortic aneurysms (TAAA), open surgical repair of TAAAs remains a formidable challenge for the vascular surgeon. It requires extensive dissection and mobilization of the aorta and its branches, as well as cross-clamping of the aorta above intercostal and visceral arteries. Over the past decade, the mortality and morbidity associated with open TAAA repair have improved significantly. However, it remains one of the most complex, extensive surgical procedures performed in the field of vascular surgery. Recently, there has been much attention directed at less invasive methods such as the so-called "hybrid" or "debranching" procedure, or complete endovascular repair with fenestrated and branched endografts for repairing TAAAs. However, the gold standard for repair of TAAA remains open surgery, and this article summarizes the clinical outcomes of open surgical repair of TAAAs during the past decade (2000-2010) to provide a benchmark for comparison with results from previous decades and also with which to compare the results of modern-day hybrid and/or complete endovascular techniques.

Acute achilles tendon rupture: Results of open surgical repair

Acute achilles tendon rupture: Results of open surgical repair

Long-Term Outcomes of Open Surgical Repair for Ruptured Iliac Artery Aneurysms

Rupture of an iliac artery aneurysm is rare but could be catastrophic unless it is treated with an appropriate strategy. We reviewed our 10-year institutional experience in treating iliac artery aneurysms to elucidate the effectiveness of open surgical repair strategies for ruptured iliac artery aneurysms in terms of short- and long-term postoperative results. A total of 26 patients (men/women = 22/4), with a mean age of 72 years, underwent open repair of iliac artery aneurysm with or without rupture (unruptured/ruptured = 15/11) between January 2001 and April 2010. There was no difference in the distribution of aneurysm morphology between the unruptured and ruptured groups, and 20 (76.9%) of the 26 patients had aneurysms involving unilateral or bilateral internal iliac arteries. Long-term event-free survival rates and freedom from secondary intervention were analyzed using the Kaplan-Meier method (follow-up: 55 ± 39 and 40 ± 25 months in the unruptured and ruptured groups, respectively). There was no difference in the time of surgery between the two groups (351 ± 118 and 348 ± 152 minutes in the unruptured and ruptured groups, respectively), but the ruptured group showed greater blood loss/min (time of surgery) and transfusion volume than the unruptured group. The early postoperative mortality was 6.7% in the unruptured group and 0% in the ruptured group (p = 0.557). There was no difference in the number of postoperative morbidities between the two groups, but the ruptured group showed significantly greater C-reactive protein, lactate dehydrogenase, and total bilirubin levels than the unruptured group. The cardiovascular event-free survival rate at 5 years was 93.3% and 100.0% in the unruptured and ruptured groups, respectively. The secondary intervention-free rate at 5 years was 100.0% and 90.0% in the unruptured and ruptured groups, respectively. The short- and long-term postoperative mortality rates after open repair for iliac artery aneurysms were satisfactorily low and similar in unruptured and ruptured groups. This suggests that open repair strategies remain as a reliable treatment option to obtain successful postoperative results in patients with rupture of an iliac artery aneurysm.

Indications and Short-term Results of Open Surgical Repair of Abdominal Aortic Aneurysm in an Endovascular Era

Purpose: To assess the role of OR in treatment of AAA patients, we reviewed the indications and our current results of OR of AAA. Methods: We retrospectively investigated the database of 366 patients (mean age, 68.3±8.7 years, male 86%) who underwent open surgical (n=291, 80%) or endovascular treatments (n=75, 20%) of AAA in a tertiary referral center between Sep. 2003 to Aug. 2010. Treatment-related morbidities and mortality rates within 30 days were investigated according to the indications for treatment, clinical features, anatomic location, and underlying causes of AAA. Results: According to the location of AAA, we treated 343 (94%) infrarenal, 17 (5%) juxtarenal and 6 (2%) suprarenal AAAs. Underlying causes of AAA were degenerative (90%), infected (3%), inflammatory (3%), Marfan’s syndrome (2%), and vasculitis (0.5%). Clinically, 338 (92%) were non-ruptured and 28 (8%) were ruptured AAAs. 75% of patients were treated with OR after the inception of reimbursement of aortic device while 25% of patients were treated with EVARs. The operative mortality rates of OR was 0.4% in patients with non-ruptured infrarenal AAA, 0% in patients with non-ruptured juxta- and suprarenal AAA and 21.4% in ruptured AAA patients. Conclusion: In an era of endovascular treatment of AAA, we have experienced excellent surgical results after OR in patients with non-ruptured AAA with various clinical features. Though EVAR is rapidly replacing OR in treatment of infrarenal AAAs, OR has its own role in treatment of AAA patients with unfavorable conditions for EVAR. The role of OR should not be underestimated.

Results of Open Pararenal Abdominal Aortic Aneurysm Repair: Tabular Review of the Literature

Open surgical repair of complex abdominal aortic aneurysms requires more extensive dissection and aortic clamping above the renal or mesenteric arteries. Although results of open surgical series have shown variation, morbidity and mortality is higher compared with infrarenal aortic aneurysm repair. Potential complications include renal insufficiency, mesenteric ischemia, multisystem organ failure, and death. Although endovascular treatment with fenestrated and branched endografts might potentially decrease the risk of complications and mortality, its role is not yet defined and the technology is not widely available. Issues related to durability of the procedure and secondary interventions might limit its application to patients with higher risk or those with hostile anatomy. This article summarizes the clinical results of open surgical repair of pararenal abdominal aortic aneurysms to provide a benchmark for comparison with results of endovascular treatment, using fenestrated and branched techniques.

Ruptured Thoracic Aneurysms

Recently published long-term outcomes of the UK Endovascular Abdominal Aortic Aneurysm Repair (EVAR) trial investigators and the Dutch Randomized Endovascular Aneurysm Repair group have continued to demonstrate the superiority of EVAR in the perioperative period, but they have failed to establish long-term sustainable durability compared to open repair because of increased graft-related complications and reinterventions.1,2 In 2005, thoracic endovascular aneurysm repair (TEVAR) was approved in the United States for the treatment of descending thoracic aortic aneurysms (DTAAs). This approval, based on the results of a phase II trial3 evaluating the GORE TAG endovascular prosthesis (W.L. Gore and Associates, Newark, Delaware), led to a nationwide explosion in the use of thoracic endovascular techniques for managing DTAAs.4 Physicians had already been performing EVAR for more than a decade. Whereas EVAR was initially used to repair abdominal aneurysms with a favorable anatomy, its use later expanded to include complex cases involving a short aneurysmal neck, a tortuous aorta, and (more recently) aneurysmal rupture. Although TEVAR has only a brief history, a similar trend is obvious: This approach is being used with reasonable success to treat dissections and even ruptured aneurysms5; in addition, various new debranching techniques are allowing TEVAR to be applied to portions of the aorta previously deemed unapproachable. Article see p 2718 Najibi and colleagues6 reported the results of the first study to compare TEVAR with open aortic repair. Their series comprised 18 patients, and the control group included a historic cohort of patients who had undergone open aortic repair during the previous 3 years. Short-term follow-up data showed that the endovascular group had significantly shorter operative times, shorter hospital and intensive-care–unit stays, and less operative blood loss. Subsequently, Bavaria and associates7 reported the results of a phase II multicenter trial that assessed GORE …

Extracranial Carotid Artery Aneurysms: Long-term Results of Open Repair

Extracranial carotid artery (ECA) aneurysms are rare, but the potential risk of rupture or thromboembolism argues for early treatment. Our goal was to determine complications and long-term outcome of open surgical repair. Clinical data of 27 patients (13 women, 14 men; mean age, 65 years) treated for ECA aneurysm at our institution between 1990 and 2009 were retrospectively reviewed. The mean ECA aneurysm size was 3.9 cm (range, 1.2-6.5 cm). Etiology in the 27 patients was pseudoaneurysm after prior carotid surgery (37%), fibromuscular dysplasia (14%), trauma (19%), atherosclerosis (19%), infection (7%), and Marfan syndrome (4%). The 22 nontraumatic aneurysms involved the internal carotid artery (ICA), and the 5 traumatic aneurysms involved the common carotid artery. Pulsatile neck mass was present in 16 patients (59%), an audible bruit was identified in 12 (44%), and 14 (56%) had a documented preoperative transient ischemic attack or stroke. Nine patients (33%) presented with concomitant aneurysms, most commonly involving the abdominal aorta. All patients underwent elective open surgical repair, including resection in 22, with interposition bypass grafting (50%), end-to-end primary repair (23%), or patch angioplasty (27%); carotid ligation in 3; and aneurysmorrhaphy in 2. There were no perioperative deaths. One patient (3.7%) sustained a neurologic embolic event with permanent visual field deficits. Transient cranial nerve injury occurred in three patients (14%), all associated with repeat surgery or high cervical lesions. During a mean follow-up of 7 years, no strokes, neurologic events, or recurrent aneurysms occurred, and five patients died of cardiac causes. Open surgical repair of ECA aneurysms can be accomplished with minimal morbidity and excellent long-term results. For most patients, open repair remains the gold standard of treatment. Patients requiring redo surgery or with distal cervical lesions have increased risk of temporary nerve injury and, therefore, may be a subgroup that would benefit from percutaneous treatment.

Importance of Aortic Morphology in Planning Aortic Interventions

Traditionally, preoperative assessment for open aortic interventions has focused on patient factors, such as cardiopulmonary status and the presence of comorbidities. These are the principal determinants of success because morbidity and mortality from such procedures is due to factors related to the incision, duration and location of the cross clamp, and the postoperative inflammatory response. These factors have been shown consistently to predict the outcome of open surgical repair of abdominal aortic aneurysms (AAA) and are incorporated in preoperative risk prediction systems, such as the Glasgow Aneurysm Score and the POSSUM predictor equation. Endovascular treatment of aortic pathology does not present such a physiological insult, as incisions are smaller and no cross-clamping is required. The postoperative inflammatory response is much less marked, and some patients can return directly to general wards after their procedure without the need for stabilization in a high-dependency environment. Perioperative and short-term mortality is reduced in endovascular repair, but increased emphasis is placed on mediumto long-term outcomes due to device failure of different types and subsequent re-intervention. The general consensus that anatomy of the diseased aorta and its branches is more important than physiological status in predicting the success of endovascular intervention has been illustrated by work showing that physiology-based risk prediction systems are not valid in endovascular aneurysm repair (EVAR) and probably not in thoracic endovascular aortic repair (TEVAR). Several classifications systems for the anatomy of the diseased aorta have been proposed. However, many existing methods are surprisingly nebulous. Dividing pathology into thoracic, thoracoabdominal, and abdominal is a useful start, as there are certain challenges unique to interventions in each area. Sub-classification into groups, particularly in relation to the visceral aortic branches, has proven difficult. For example, the meaning of ‘‘juxtarenal’’ in terms of an AAA simply means that a crossclamp cannot be applied below the renal arteries. This is not a particularly objective definition. The traditional Crawford type classificationofdescending thoracicaneurysms isnot necessarily applicable to endovascular repair, but the length of aortic coverage is important from the perspective of postoperative paraplegia. It is known that certain anatomical features predispose to the risk of adverse outcome. At present, there is no universally accepted classification system for the anatomyof the aorta with regards to location of interventions.

Invited commentary

Invited commentary