- Email: [email protected]
Open Surgical Repair of Thoracoabdominal Aortic Aneurysms
Basic Data Underlying Clinical Decision-Making in Endovascular Therapy Open Surgical Repair of Thoracoabdominal Aortic Aneurysms Michele Piazza,1 and Joseph J. Ricotta II,2 Padova, Italy, and Atlanta, Georgia
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 (2000e2010) 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.
INTRODUCTION Open surgical repair of thoracoabdominal aortic aneurysms (TAAA) remains one of the most, if not the most, complex and extensive operations in vascular surgery, and obtaining successful outcomes remains a formidable challenge to the vascular and cardiovascular surgeon. It requires extensive dissection and mobilization of the aorta and its branches, as well as cross-clamping of the aorta above the intercostal and visceral arteries. The most frequent complications after this procedure include respiratory failure, renal failure, spinal cord injury, multisystem organ failure, and death. Recently, there 1 Clinica di Chirurgia Vascolare ed Endovascolare, Universita’ degli Studi di Padova, Padova, Italy. 2 Division of Vascular Surgery and Endovascular Therapy, Emory University School of Medicine, Atlanta, GA.
Correspondence to: Joseph J. Ricotta II, MD, Division of Vascular Surgery and Endovascular Therapy, Emory University School of Medicine, The Emory Clinic, 1365 Clifton Road North East, Building A, Suite 3200, Atlanta, GA 30322, USA; E-mail: [email protected] Ann Vasc Surg 2012; 26: 600e605 DOI: 10.1016/j.avsg.2011.11.002 Ó Annals of Vascular Surgery Inc. Published online: December 21, 2011
600
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. These less invasive techniques may potentially lead to a decrease in morbidity and mortality; however, their roles in the treatment of patients with TAAAs are not yet defined and the technology is not widely available. In addition, issues related to durability of these procedures and secondary interventions might limit their application to patients with higher risk or to those with hostile anatomy. Furthermore, the need for close imaging surveillance with endovascular repair has potential risks for renal function deterioration, and this may limit its use in good-risk patients who would be considered candidates for open surgery. On the other hand, the potential deleterious effects of visceral and spinal ischemia contribute to the morbidity and mortality rate after open surgery. In this article, the published data of the past decade (2000e2010) for open TAAA surgical repair have been reviewed. Fortunately, there has been a dramatic improvement in the pre-, intra-, and
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Open surgical repair of TAAA 601
Table I. Preoperative characteristics Variables
Demographics Male Mean age (years) Cardiovascular risk factor Hypertension Tobacco Hyperlipidemia Diabetes CAD Previous MI Pulmonary disease Chronic renal failure Dialysis Previous CABG/PTCA CHF CVD PAOD VOD
N (7,780+)
% (range)
References
3,878/6,463 70.21
60 (48-100) 53-75
2-17 2-10,13-18
3,993/5,091 424/684 8/19 270/3,806 2,301/6,579 8/90 1,674/4,467 799/5,162 48/2,885 495/2,859 4/49 471/3,571 26/484 15/50
78.43 61.98 42.1 7.09 34.97 8.8 37.47 15.47% 1.66 17.31 8.16 13.18 5.37 30
2,3,5-13,10,12,15,17 3,5,6,9,12,16 6 2,5-9,12,16,17 2,3,5,7-10,12,14-18 12 2,3,5,7-9,12,14-17 2,3,5,7,9,10,12,14,15,17,18 7,12,15 5,7,13,12 5 3,5,7,13,12,15,18 13,14 14
(73.1-88.28) (31.57-98.0) (-) (5.26-12.21) (3.22-65.3) (-) (7.7-57.35) (2.94-36.8) (1.37-2.2) (14.51-23.3) (-) (6.12-21.65) (5.06-8) (-)
CAD, coronary artery disease; MI, myocardial infarction; CABG/PTCA, coronary artery bypass graft/percutaneous transluminal coronary angioplasty; CHF, chronic heart failure; CVD, cerebrovascular disease; PAOD, peripheral arterial occlusive disease; VOD, visceral occlusive disease.
Table II. Preoperative presentation Variables
Presentation Asymptomatic Symptomatic Rupture Operative indication Elective Urgent/emergent Extent of aneurysm Type I Type II Type III Type IV Etiology Degenerative Marfan syndrome Dissection EhlerseDanlos syndrome Mycotic Inflammatory Natural historya Overall death Rupture-related death Not related death a
N
% (range)
References
67,58 (63.6-92) 32.55 (8-51.02) 8.76 (1.8-19.8)
3,8,14,16 3,8,14,16 2,3,14-17,19-21
77.81 (57.42-92) 19.35 (10.4-42.57)
2,3,12,14,15,17,20,21 2,3,8,12,14,15,17,19,20,21
777/3,138 700/3,138 839/3,138 811/3,138
24.76 22.3 26.73 25.84
(8.69-32.6) (14.28-52.17) (15.26-38.8) (4.11-52.9)
2-4,6,8,9,13,15,17-20,22-25 2-4,6,8,9,13,15,17-20,22-25 2-4,6,8,9,13,15,17-20,22-25 2-4,6,8,9,13,15,17-20,22-25
2,268/3,110 96/1,328 1,050/3,669 3/90 5/220 16/606
72.92 7.2 28.61 3.3 2.27 2.64
(62.2-79.27) (3.5-40) (18.9-44) (-) (2-2.35) (1.5-13.2)
2,6,7,12,17,19,24 2,12,14,15 2,6,7,12,14,15,17,19,24 12 2,14 2,14,16,17
465/688 223/685 138/1,574 1,119/1,438 396/2,046
49/89 23/89 26/89
55 (-) 25.8 (-) 29.21 (-)
13 13 13
1 year mean follow-up.
postoperative management of this complex disease over the past decade, which has led to a reduction in early mortality and neurologic complications compared with the past decade (1990e2000). In
fact, comparing our review with a similar one by Panneton and Hollier1 published in 1995, there has been a mean range reduction of 30-day mortality (from 10% to 7%) and the advances in
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Table III. Associated or previous aneurysm repair Variables
N
Synchronous aneurysm Proximal (ascending, arch) Other aortic segment Previous repair Proximal (ascending, arch, thoracic) AAA Not specified previous aortic
% (range)
References
62/443 23/333
13.99 (12.31-19.09) 6.9 (-)
23,19 23
236/1,715 362/1,822 123/263
13.76 (7.5-52) 19.86 (15.8-22) 46.76 (38.15-66.3)
2,4,8,9,20,14,17 2,4,8,9,20,14,21,17 19,12
AAA, abdominal aortic aneurysm.
Table IV. Operative characteristics Variables
Technique Clamp and repair DAPa Hypothermic circulatory arrest Spinal cord protection (method) Cerebrospinal fluid drainage SSEP monitoring MEP monitoring Spinal artery localization Intercostal artery reimplantation Epidural cooling
n
% (range)
References
475/503 1,707/3,629 273/996
94.43 (92.79-97.6) 47.03 (39.02-94) 27.4 (2.16-100)
2,17 3-5,7,12,14,15,26,27 19,12,15,27
1,569/3,649 118/118 35/90 66/66 2,542/5,050 328/1,015
42.9 100 38.8 100 50.3 32.31
3,5-7,12,14,15,18,19,26,27 6,12 12 24 2,7,10,14,15,17,26,27 2,11,18,22
(1.7-100) (-) (-) (-) (2.4-66) (0-100)
SSEP, somatosensory-evoked potential; MEP, motor-evoked potential. a Distal aortic perfusion by shunt or partial extracorporeal circulation.
Table V. Early mortality Variables
N
% (range)
References
Intraoperative mortality 30-d mortality In-hospital mortality Operative indication Elective mortality Emergent mortality Extent Type I Type II Type III Type IV
84/3,418 349/4,943 201/2,003
2.45 (0.9-7.85) 7.06 (4.21-17.85) 10.03 (2.35-21.8)
5,7,11,15,17 2,4-7,9,11,14-16,19-22,27 3,11,12,15,18,20,23,27
31/612 28/148
5.06 (1.29-10.34) 18.91 (13.41-40)
3,5,12,17 3,5,12,17
48/833 77/932 42/541 30/684
spinal cord protection have contributed to an overall reduction of spinal cord ischemia (from 14% to 7.5%). However, renal (from 18% to 19.8%) and pulmonary complications (from 32% to 31%) remain a significant challenge, despite medical and surgical advances. There has been no difference in long-term survival over the past 20 years or so (approximately 60% for both reviews). The purpose of this report was to provide all available clinical data regarding presentation,
5.76 8.26 7.76 4.38
(1.96-16.9) (8.16-36.1) (0-24.48) (0-22.2)
7,9,22,27 7,9,19,22,27 7,9,19,22,27 7,9,16,21,22,27
management, and results of open TAAA surgery 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.
METHODS This tabular review includes all reports, published between 2000 and 2010, of patients treated with
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Open surgical repair of TAAA 603
Table VI. Causes of early mortality and postoperative complications Causes
N
Operative and early mortality causes MI/cardiac Stroke Hemorrhage Pulmonary MOF Visceral infarction Sepsis Early complications not causing death MI Cardiac complications Stroke Hemorrhage need OR Renal Temporary dialysis Permanent dialysis Pulmonary Tracheostomy Branches occlusion/thrombectomy Reoperation visceral ischemia Multisystem organ system failure Spinal cord injurya Paraplegia Immediate onset Delayed onset Permanent Paraparesis Immediate onset Delayed onset Permanent
% (range)
28/1,303 21/1,239 8/837 26/1,353 39/1,001 14/1,408 1/509
2.14 1.69 0.95 1.92 3.89 0.99 0.19
25/459 392/3,499 108/3,898 138/3,541 361/1,815 49/763 191/3,376 1241/3,954 69/500 17/526 15/485 71/567 299/3,999 71/1,023 19/842 36/842 16/586 39/1,023 17/842 42/842 33/509
5.44 11.2 2.77 3.89 19.88 6.42 5.65 31.38 13.8 3.23 3.09 12.52 7.47 6.94 2.25 4.27 2.73 3.81 2.01 4.98 6.48
References
(0.58-2.45) (1.40-2.04) (0.19-2.35) (1.22-2.75) (2.94-6) (0.58-2) (-)
2,11,15,16 5,11,15,19 2,14,15 2,11,14-16 2,5,11,14,16,21 2,11,14,15,21 15
(3.9-10.2) (3.33-26.7) (1.29-6.12) (2.22-12.05) (5.37-42.85) (4.44-10.2) (4.8-7.77) (7.88-44.14) (11.41-20) (2.59-3.6) (2.1-7.54) (10.41-31.03) (2-28.12) (1.88-8.57) (0.78-4.5) (2.1-5.69) (2.55-3.89) (2.97-7.14) (1.17-3.3) (1.5-7.26) (-)
5,17,20 2,3,7,12,15-17 2,5,7,14,15,17,19,20,27 5,7,12,14,15,17,27 2-5,12,14-17,27 5,11,12,16 7,12,14,15,17,21 2-5,7,12,14-17,20 12,17,20 14,17 5,14,16,17 3,15 3,7,9,12,14,17,19,27,28 4,6,11,16,17,22 15,17 15,17 15,20 5,11,17,22 15,17 15,17 15
MOF, multi-organ failure; OR, operating room. a Paraplegia or paraparesis.
Table VII. Late survival
Survival elective 1 year 2 years 3 years 5 years Survival rupture 1 year 2 years a
Range (%)
Mean (%)
References
73-96 61-81.2 71-92.5 37-85.4
84.56 73.6 75.3 61.2
3,9,15,16,19-21a,23 5,15,17 15,16,18,19,21 5,17-19,21a-23,28
53.7 47.1
26 26
-
Only type IV thoracoabdominal aneurysm.
open surgical repair of TAAA. The main concern in reviewing all previous clinical experiences is the problem of mixed series. Reports on TAAA surgery tend to blend together descending thoracic aortic aneurysm with TAAAs. Furthermore, results for chronic dissecting aneurysm are often combined
with results for degenerative TAAAs. In our analysis of the literature, weighted ranges have been calculated when possible, and when the data could be considered of nondissecting TAAAs only. The search for the published data for this review was performed using the PubMed database, focusing on combination of keywords such as ‘‘open repair,’’ ‘‘surgical repair,’’ and ‘‘thoracoabdominal aortic aneurysm.’’ This search yielded more than 5,000 reports. At this point, we excluded all reports with <20 patients, reports of hybrid or endovascular series, case reports, and reviews. We obtained 54 papers and after excluding those reports with no clear differentiations for etiology and/or mixed with cases where the vast majority were thoracic aneurysms, we identified 27 papers with a total of 7,833 patients. The clinical data extracted from selected reports are allocated as they appear in crude values, means, and percentages. The tabular data include demographic and cardiovascular risk factors
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Table VIII. Mortality predictive variables References
Preoperative Age >75 Preoperative respiratory disease Preoperative renal dysfunction Preoperative CAD Aneurysm extent Emergent/rupture Intraoperative Intraoperative hypotension Duration of visceral ischemia Blood transfusion requirement Postoperative Postoperative respiratory failure Postoperative renal failure/dialysis Postoperative paraplegia Postoperative cerebrovascular accident Infection
3,11,15 15 21 3 5,7,18,27 5,15,17 17,26 3 17,26 17,18 3,11a,17 4,17,27,28 18,27 18
Table IX. Neurologic deficit predictive variables References
Preoperative Rupture or shock Symptomatic or emergent operation TAAA type I-II Intraoperative Aortic cross-clamp duration Hypotension T9L2 intercostal sacrifice Postoperative Pulmonary complications Renal failure
17 17 7,9,10,17 10,17 2,17 2,17 17 2,17
(Table I); clinical presentation, extent of aneurysm, etiology, and natural history (Table II); other associated aneurysmal disease and previous aortic repair (Table III); surgical technique and spinal cord protection methods (Table IV); overall early mortality stratified according to the TAAA Crawford type classification (Table V); causes of early mortality and complications (Table VI); late survival stratified by elective repair and urgent or emergent repair for ruptures aneurysms (Table VII); and predictive variables for mortality and neurologic deficit (Tables VIII and IX). The gold standard for repair of TAAA remains open surgery, and in assimilating and summarizing the world’s literature for open surgical repair of TAAAs over the past decade, the authors intend for this review to provide a benchmark for comparison with results of open TAAA surgery from previous decades and also with which to compare the results
of modern-day hybrid and/or complete endovascular techniques, as well as be used as a practical and prompt literature search tool for all surgeons and endovascular specialists who encounter this difficult disease process in their practices. REFERENCES 1. Pannetton JM, Hollier LH. Nondissecting thoracoabdominal aortic aneurysms: part I. Ann Vasc Surg 1995;9:503e14. 2. Cambria RP, Davison JK, Carter C, et al. Epidural cooling for spinal cord protection during thoracoabdominal aneurysm repair: a five-year experience. J Vasc Surg 2000;31:1093e102. 3. Rectenwald JE, Huber TS, Martin TD, et al. Functional outcome after thoracoabdominal aortic aneurysm repair. J Vasc Surg 2002;35:640e7. 4. Lombardi JV, Carpenter JP, Pochettino A, et al. Thoracoabdominal aortic aneurysm repair after prior aortic surgery. J Vasc Surg 2003;38:1185e90. 5. Menard MT, Nguyen LL, Chan RK, et al. Thoracovisceral segment aneurysm repair after previous infrarenal abdominal aortic aneurysm surgery. J Vasc Surg 2004;39:1163e70. 6. Weigang E, Hartert M, von Samson P, et al. Thoracoabdominal aortic aneurysm repair: interplay of spinal cord protecting modalities. Eur J Vasc Endovasc Surg 2005;30:624e31. 7. Coselli JS, Bozinovski J, LeMaire SA. Open surgical repair of 2286 thoracoabdominal aortic aneurysms. Ann Thorac Surg 2007;83:S862e4. discussion S890e2. 8. Crawford RS, Pedraza JD, Chung TK, et al. Functional outcome after thoracoabdominal aneurysm repair. J Vasc Surg 2008;48:828e35. 9. Greenberg RK, Lu Q, Roselli EE, et al. Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques. Circulation 2008;118:808e17. 10. Safi HJ, Estrera AL, Azizzadeh A, et al. Progress and future challenges in thoracoabdominal aortic aneurysm management. World J Surg 2008;32:355e60. 11. Schepens MA, Heijmen RH, Ranschaert W, et al. Thoracoabdominal aortic aneurysm repair: results of conventional open surgery. Eur J Vasc Endovasc Surg 2009;37:640e5. 12. Etz CD, Zoli S, Mueller CS, et al. Staged repair significantly reduces paraplegia rate after extensive thoracoabdominal aortic aneurysm repair. J Thorac Cardiovasc Surg 2010;139:1464e72. 13. Hansen PA, Richards JM, Tambyraja AL, et al. Natural history of thoraco-abdominal aneurysm in high-risk patients. Eur J Vasc Endovasc Surg 2010;39:266e70. 14. De Rango P, Estrera AL, Miller C 3rd, et al. Operative outcomes using a side-branched thoracoabdominal aortic graft (STAG) for thoraco-abdominal aortic repair. Eur J Vasc Endovasc Surg 2011;41:41e7. 15. Wong DR, Parenti JL, Green SY, et al. Open repair of thoracoabdominal aortic aneurysm in the modern surgical era: contemporary outcomes in 509 patients. J Am Coll Surg 2011;212:569e79. 16. Richards JM, Nimmo AF, Moores CR, et al. Contemporary results for open repair of suprarenal and type IV thoracoabdominal aortic aneurysms. Br J Surg 2010;97:45e9. 17. Cambria RP, Clouse WD, Davison JK, et al. Thoracoabdominal aneurysm repair: results with 337 operations performed over a 15-year interval. Ann Surg 2002;236:471e9. discussion 479. 18. Tabayashi K, Saiki Y, Kokubo H, et al. Protection from postischemic spinal cord injury by perfusion cooling of the
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19.
20.
21.
22.
23.
epidural space during most or all of a descending thoracic or thoracoabdominal aneurysm repair. Gen Thorac Cardiovasc Surg 2010;58:228e34. Fehrenbacher JW, Hart DW, Huddleston E, et al. Optimal end-organ protection for thoracic and thoracoabdominal aortic aneurysm repair using deep hypothermic circulatory arrest. Ann Thorac Surg 2007;83:1041e6. Patel R, Conrad MF, Paruchuri V, et al. Thoracoabdominal aneurysm repair: hybrid versus open repair. J Vasc Surg 2009;50:15e22. Nathan DP, Brinster CJ, Woo EY, et al. Predictors of early and late mortality following open extent IV thoracoabdominal aortic aneurysm repair in a large contemporary singlecenter experience. J Vasc Surg 2011;53:299e306. Gloviczki P. Surgical repair of thoracoabdominal aneurysms: patient selection, techniques and results. Cardiovasc Surg 2002;10:434e41. Clouse WD, Marone LK, Davison JK, et al. Late aortic and graft-related events after thoracoabdominal aneurysm repair. J Vasc Surg 2003;37:254e61.
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24. Nijenhuis RJ, Jacobs MJ, Jaspers K, et al. Comparison of magnetic resonance with computed tomography angiography for preoperative localization of the Adamkiewicz artery in thoracoabdominal aortic aneurysm patients. J Vasc Surg 2007;45:677e85. 25. Mell MW, Wynn MM, Reeder SB, et al. A new intercostal artery management strategy for thoracoabdominal aortic aneurysm repair. J Surg Res 2009;154:99e104. 26. Barbato JE, Kim JY, Zenati M, et al. Contemporary results of open repair of ruptured descending thoracic and thoracoabdominal aortic aneurysms. J Vasc Surg 2007;45: 667e76. 27. Messe SR, Bavaria JE, Mullen M, et al. Neurologic outcomes from high risk descending thoracic and thoracoabdominal aortic operations in the era of endovascular repair. Neurocrit Care 2008;9:344e51. 28. Conrad MF, Ye JY, Chung TK, et al. Spinal cord complications after thoracic aortic surgery: long-term survival and functional status varies with deficit severity. J Vasc Surg 2008;48:47e53.
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 (2000e2010) 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.
INTRODUCTION Open surgical repair of thoracoabdominal aortic aneurysms (TAAA) remains one of the most, if not the most, complex and extensive operations in vascular surgery, and obtaining successful outcomes remains a formidable challenge to the vascular and cardiovascular surgeon. It requires extensive dissection and mobilization of the aorta and its branches, as well as cross-clamping of the aorta above the intercostal and visceral arteries. The most frequent complications after this procedure include respiratory failure, renal failure, spinal cord injury, multisystem organ failure, and death. Recently, there 1 Clinica di Chirurgia Vascolare ed Endovascolare, Universita’ degli Studi di Padova, Padova, Italy. 2 Division of Vascular Surgery and Endovascular Therapy, Emory University School of Medicine, Atlanta, GA.
Correspondence to: Joseph J. Ricotta II, MD, Division of Vascular Surgery and Endovascular Therapy, Emory University School of Medicine, The Emory Clinic, 1365 Clifton Road North East, Building A, Suite 3200, Atlanta, GA 30322, USA; E-mail: [email protected] Ann Vasc Surg 2012; 26: 600e605 DOI: 10.1016/j.avsg.2011.11.002 Ó Annals of Vascular Surgery Inc. Published online: December 21, 2011
600
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. These less invasive techniques may potentially lead to a decrease in morbidity and mortality; however, their roles in the treatment of patients with TAAAs are not yet defined and the technology is not widely available. In addition, issues related to durability of these procedures and secondary interventions might limit their application to patients with higher risk or to those with hostile anatomy. Furthermore, the need for close imaging surveillance with endovascular repair has potential risks for renal function deterioration, and this may limit its use in good-risk patients who would be considered candidates for open surgery. On the other hand, the potential deleterious effects of visceral and spinal ischemia contribute to the morbidity and mortality rate after open surgery. In this article, the published data of the past decade (2000e2010) for open TAAA surgical repair have been reviewed. Fortunately, there has been a dramatic improvement in the pre-, intra-, and
Vol. 26, No. 4, May 2012
Open surgical repair of TAAA 601
Table I. Preoperative characteristics Variables
Demographics Male Mean age (years) Cardiovascular risk factor Hypertension Tobacco Hyperlipidemia Diabetes CAD Previous MI Pulmonary disease Chronic renal failure Dialysis Previous CABG/PTCA CHF CVD PAOD VOD
N (7,780+)
% (range)
References
3,878/6,463 70.21
60 (48-100) 53-75
2-17 2-10,13-18
3,993/5,091 424/684 8/19 270/3,806 2,301/6,579 8/90 1,674/4,467 799/5,162 48/2,885 495/2,859 4/49 471/3,571 26/484 15/50
78.43 61.98 42.1 7.09 34.97 8.8 37.47 15.47% 1.66 17.31 8.16 13.18 5.37 30
2,3,5-13,10,12,15,17 3,5,6,9,12,16 6 2,5-9,12,16,17 2,3,5,7-10,12,14-18 12 2,3,5,7-9,12,14-17 2,3,5,7,9,10,12,14,15,17,18 7,12,15 5,7,13,12 5 3,5,7,13,12,15,18 13,14 14
(73.1-88.28) (31.57-98.0) (-) (5.26-12.21) (3.22-65.3) (-) (7.7-57.35) (2.94-36.8) (1.37-2.2) (14.51-23.3) (-) (6.12-21.65) (5.06-8) (-)
CAD, coronary artery disease; MI, myocardial infarction; CABG/PTCA, coronary artery bypass graft/percutaneous transluminal coronary angioplasty; CHF, chronic heart failure; CVD, cerebrovascular disease; PAOD, peripheral arterial occlusive disease; VOD, visceral occlusive disease.
Table II. Preoperative presentation Variables
Presentation Asymptomatic Symptomatic Rupture Operative indication Elective Urgent/emergent Extent of aneurysm Type I Type II Type III Type IV Etiology Degenerative Marfan syndrome Dissection EhlerseDanlos syndrome Mycotic Inflammatory Natural historya Overall death Rupture-related death Not related death a
N
% (range)
References
67,58 (63.6-92) 32.55 (8-51.02) 8.76 (1.8-19.8)
3,8,14,16 3,8,14,16 2,3,14-17,19-21
77.81 (57.42-92) 19.35 (10.4-42.57)
2,3,12,14,15,17,20,21 2,3,8,12,14,15,17,19,20,21
777/3,138 700/3,138 839/3,138 811/3,138
24.76 22.3 26.73 25.84
(8.69-32.6) (14.28-52.17) (15.26-38.8) (4.11-52.9)
2-4,6,8,9,13,15,17-20,22-25 2-4,6,8,9,13,15,17-20,22-25 2-4,6,8,9,13,15,17-20,22-25 2-4,6,8,9,13,15,17-20,22-25
2,268/3,110 96/1,328 1,050/3,669 3/90 5/220 16/606
72.92 7.2 28.61 3.3 2.27 2.64
(62.2-79.27) (3.5-40) (18.9-44) (-) (2-2.35) (1.5-13.2)
2,6,7,12,17,19,24 2,12,14,15 2,6,7,12,14,15,17,19,24 12 2,14 2,14,16,17
465/688 223/685 138/1,574 1,119/1,438 396/2,046
49/89 23/89 26/89
55 (-) 25.8 (-) 29.21 (-)
13 13 13
1 year mean follow-up.
postoperative management of this complex disease over the past decade, which has led to a reduction in early mortality and neurologic complications compared with the past decade (1990e2000). In
fact, comparing our review with a similar one by Panneton and Hollier1 published in 1995, there has been a mean range reduction of 30-day mortality (from 10% to 7%) and the advances in
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Table III. Associated or previous aneurysm repair Variables
N
Synchronous aneurysm Proximal (ascending, arch) Other aortic segment Previous repair Proximal (ascending, arch, thoracic) AAA Not specified previous aortic
% (range)
References
62/443 23/333
13.99 (12.31-19.09) 6.9 (-)
23,19 23
236/1,715 362/1,822 123/263
13.76 (7.5-52) 19.86 (15.8-22) 46.76 (38.15-66.3)
2,4,8,9,20,14,17 2,4,8,9,20,14,21,17 19,12
AAA, abdominal aortic aneurysm.
Table IV. Operative characteristics Variables
Technique Clamp and repair DAPa Hypothermic circulatory arrest Spinal cord protection (method) Cerebrospinal fluid drainage SSEP monitoring MEP monitoring Spinal artery localization Intercostal artery reimplantation Epidural cooling
n
% (range)
References
475/503 1,707/3,629 273/996
94.43 (92.79-97.6) 47.03 (39.02-94) 27.4 (2.16-100)
2,17 3-5,7,12,14,15,26,27 19,12,15,27
1,569/3,649 118/118 35/90 66/66 2,542/5,050 328/1,015
42.9 100 38.8 100 50.3 32.31
3,5-7,12,14,15,18,19,26,27 6,12 12 24 2,7,10,14,15,17,26,27 2,11,18,22
(1.7-100) (-) (-) (-) (2.4-66) (0-100)
SSEP, somatosensory-evoked potential; MEP, motor-evoked potential. a Distal aortic perfusion by shunt or partial extracorporeal circulation.
Table V. Early mortality Variables
N
% (range)
References
Intraoperative mortality 30-d mortality In-hospital mortality Operative indication Elective mortality Emergent mortality Extent Type I Type II Type III Type IV
84/3,418 349/4,943 201/2,003
2.45 (0.9-7.85) 7.06 (4.21-17.85) 10.03 (2.35-21.8)
5,7,11,15,17 2,4-7,9,11,14-16,19-22,27 3,11,12,15,18,20,23,27
31/612 28/148
5.06 (1.29-10.34) 18.91 (13.41-40)
3,5,12,17 3,5,12,17
48/833 77/932 42/541 30/684
spinal cord protection have contributed to an overall reduction of spinal cord ischemia (from 14% to 7.5%). However, renal (from 18% to 19.8%) and pulmonary complications (from 32% to 31%) remain a significant challenge, despite medical and surgical advances. There has been no difference in long-term survival over the past 20 years or so (approximately 60% for both reviews). The purpose of this report was to provide all available clinical data regarding presentation,
5.76 8.26 7.76 4.38
(1.96-16.9) (8.16-36.1) (0-24.48) (0-22.2)
7,9,22,27 7,9,19,22,27 7,9,19,22,27 7,9,16,21,22,27
management, and results of open TAAA surgery 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.
METHODS This tabular review includes all reports, published between 2000 and 2010, of patients treated with
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Open surgical repair of TAAA 603
Table VI. Causes of early mortality and postoperative complications Causes
N
Operative and early mortality causes MI/cardiac Stroke Hemorrhage Pulmonary MOF Visceral infarction Sepsis Early complications not causing death MI Cardiac complications Stroke Hemorrhage need OR Renal Temporary dialysis Permanent dialysis Pulmonary Tracheostomy Branches occlusion/thrombectomy Reoperation visceral ischemia Multisystem organ system failure Spinal cord injurya Paraplegia Immediate onset Delayed onset Permanent Paraparesis Immediate onset Delayed onset Permanent
% (range)
28/1,303 21/1,239 8/837 26/1,353 39/1,001 14/1,408 1/509
2.14 1.69 0.95 1.92 3.89 0.99 0.19
25/459 392/3,499 108/3,898 138/3,541 361/1,815 49/763 191/3,376 1241/3,954 69/500 17/526 15/485 71/567 299/3,999 71/1,023 19/842 36/842 16/586 39/1,023 17/842 42/842 33/509
5.44 11.2 2.77 3.89 19.88 6.42 5.65 31.38 13.8 3.23 3.09 12.52 7.47 6.94 2.25 4.27 2.73 3.81 2.01 4.98 6.48
References
(0.58-2.45) (1.40-2.04) (0.19-2.35) (1.22-2.75) (2.94-6) (0.58-2) (-)
2,11,15,16 5,11,15,19 2,14,15 2,11,14-16 2,5,11,14,16,21 2,11,14,15,21 15
(3.9-10.2) (3.33-26.7) (1.29-6.12) (2.22-12.05) (5.37-42.85) (4.44-10.2) (4.8-7.77) (7.88-44.14) (11.41-20) (2.59-3.6) (2.1-7.54) (10.41-31.03) (2-28.12) (1.88-8.57) (0.78-4.5) (2.1-5.69) (2.55-3.89) (2.97-7.14) (1.17-3.3) (1.5-7.26) (-)
5,17,20 2,3,7,12,15-17 2,5,7,14,15,17,19,20,27 5,7,12,14,15,17,27 2-5,12,14-17,27 5,11,12,16 7,12,14,15,17,21 2-5,7,12,14-17,20 12,17,20 14,17 5,14,16,17 3,15 3,7,9,12,14,17,19,27,28 4,6,11,16,17,22 15,17 15,17 15,20 5,11,17,22 15,17 15,17 15
MOF, multi-organ failure; OR, operating room. a Paraplegia or paraparesis.
Table VII. Late survival
Survival elective 1 year 2 years 3 years 5 years Survival rupture 1 year 2 years a
Range (%)
Mean (%)
References
73-96 61-81.2 71-92.5 37-85.4
84.56 73.6 75.3 61.2
3,9,15,16,19-21a,23 5,15,17 15,16,18,19,21 5,17-19,21a-23,28
53.7 47.1
26 26
-
Only type IV thoracoabdominal aneurysm.
open surgical repair of TAAA. The main concern in reviewing all previous clinical experiences is the problem of mixed series. Reports on TAAA surgery tend to blend together descending thoracic aortic aneurysm with TAAAs. Furthermore, results for chronic dissecting aneurysm are often combined
with results for degenerative TAAAs. In our analysis of the literature, weighted ranges have been calculated when possible, and when the data could be considered of nondissecting TAAAs only. The search for the published data for this review was performed using the PubMed database, focusing on combination of keywords such as ‘‘open repair,’’ ‘‘surgical repair,’’ and ‘‘thoracoabdominal aortic aneurysm.’’ This search yielded more than 5,000 reports. At this point, we excluded all reports with <20 patients, reports of hybrid or endovascular series, case reports, and reviews. We obtained 54 papers and after excluding those reports with no clear differentiations for etiology and/or mixed with cases where the vast majority were thoracic aneurysms, we identified 27 papers with a total of 7,833 patients. The clinical data extracted from selected reports are allocated as they appear in crude values, means, and percentages. The tabular data include demographic and cardiovascular risk factors
604 Piazza and Ricotta
Annals of Vascular Surgery
Table VIII. Mortality predictive variables References
Preoperative Age >75 Preoperative respiratory disease Preoperative renal dysfunction Preoperative CAD Aneurysm extent Emergent/rupture Intraoperative Intraoperative hypotension Duration of visceral ischemia Blood transfusion requirement Postoperative Postoperative respiratory failure Postoperative renal failure/dialysis Postoperative paraplegia Postoperative cerebrovascular accident Infection
3,11,15 15 21 3 5,7,18,27 5,15,17 17,26 3 17,26 17,18 3,11a,17 4,17,27,28 18,27 18
Table IX. Neurologic deficit predictive variables References
Preoperative Rupture or shock Symptomatic or emergent operation TAAA type I-II Intraoperative Aortic cross-clamp duration Hypotension T9L2 intercostal sacrifice Postoperative Pulmonary complications Renal failure
17 17 7,9,10,17 10,17 2,17 2,17 17 2,17
(Table I); clinical presentation, extent of aneurysm, etiology, and natural history (Table II); other associated aneurysmal disease and previous aortic repair (Table III); surgical technique and spinal cord protection methods (Table IV); overall early mortality stratified according to the TAAA Crawford type classification (Table V); causes of early mortality and complications (Table VI); late survival stratified by elective repair and urgent or emergent repair for ruptures aneurysms (Table VII); and predictive variables for mortality and neurologic deficit (Tables VIII and IX). The gold standard for repair of TAAA remains open surgery, and in assimilating and summarizing the world’s literature for open surgical repair of TAAAs over the past decade, the authors intend for this review to provide a benchmark for comparison with results of open TAAA surgery from previous decades and also with which to compare the results
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