Analysis of ascending and transverse aortic arch repair in octogenarians.

BACKGROUND: Increasing numbers of older patients are requiring complex thoracic aortic surgery. This retrospective study analyzed early and late outcomes after ascending and transverse arch surgery using hypothermic circulatory arrest (HCA). METHODS: Between January 1991 and December 2006, 779 patients requiring HCA were treated. Outcomes are reported by age group: group 1, 80 years or more (37, 4.8%); and group 2, less than 80 years (742, 95.2%). Univariate and multivariate analyses were used to identify risk factors for morbidity and mortality. RESULTS: Early mortality and stroke did not differ between groups. Thirty-day mortality was13.5% (5 of 37) in group 1 and 10% (78 of 742) in group 2 (p = 0.57). Stroke occurred in 8% (3 of 37) of group 1 patients and 2.7% (20 of 742) of group 2 patients (p = 0.09). Predictors of stroke were prior stroke (p = 0.003) and pump time (p = 0.02). Predictors of early mortality were low glomerular filtration rate (p = 0.0001), long cardiopulmonary bypass time (p = 0.0001), and emergent repair (p = 0.0009). Retrograde cerebral perfusion was protective against stroke (p = 0.0001) and reduced early mortality (p = 0.02). Age was not a predictor of stroke (p = 0.12) or early mortality (p = 0.39). Survival in group 1 compared with the age-matched US population at 1 year was 56% versus 86% (p = 0.02); at 2 years, 48% versus 76% (p = 0.03); at 5 years, 36% versus 48% (not significant); and at 10 years, 20% versus 20%. CONCLUSIONS: Ascending and aortic arch surgery in octogenarians involving profound HCA resulted in reasonable morbidity and short- and long-term mortality rates. The use of profound HCA for aortic surgery remains warranted in octogenarians.

Outcomes of delayed sternal closure after complex aortic surgery.

OBJECTIVE: Open chest management during complex proximal aortic surgery may sometimes be necessary. Infectious complications such as mediastinitis and late aortic graft infection remain a concern. The objective of this study was to report our experience with open chest management and delayed sternal closure after complex proximal aortic surgery. METHODS: Between 1991 and 2007, 12 patients (1.2%, 12/1011) required open chest management and delayed sternal closure. Eight patients were men (67%), with a mean age of 56 years (range 28-83 years). Four cases involved redo-median sternotomy (33%) and seven cases (58%) involved acute dissection. All procedures were performed using total cardiopulmonary bypass with profound hypothermic circulatory arrest. Reasons for open chest management included hemodynamic instability, mediastinal edema, bleeding, and respiratory compromise. RESULTS: In-hospital mortality was 16.7% (2/12). Delayed sternal closure was achieved in 92% of patients (11/12). Mean time to closure was 3 days (range 1-9 days). Five patients (42%) required one or more mediastinal explorations prior to final closure. Mean length of stay was 51 days (range 1-186 days). Significant predictors of open chest management were pump time (p<0.0001) and intra-operative blood transfusions (p<0.002). Mean follow-up was 60 months (range 8-106 months). No patients developed mediastinitis or aortic graft infection during postoperative follow-up. CONCLUSIONS: Open chest management with delayed sternal closure after complex aortic repairs may be performed with acceptable mortality. Open chest management does not appear to increase the risk of infectious complications (mediastinitis or graft infections) during complex proximal aortic replacement.

Proximal reoperations after repaired acute type A aortic dissection.

BACKGROUND: Concerned with the associated risks of proximal reoperation, some have proposed an aggressive approach of aortic root replacement during emergent repair of acute type A aortic dissection. Because few data exist regarding late reoperations, we report outcomes of proximal reoperation after repaired type A aortic dissection. METHODS: Between January 1991 and March 2006, 63 patients underwent reoperation after previous repair for acute type A aortic dissection. Procedures performed at reoperation included ascending (94%, 59 of 63), total arch (62%, 39 of 63), elephant trunk (56%, 35 of 63), aortic valve replacement (38%, 24 of 63), aortic root (27%, 17 of 63), and coronary artery bypass graft (8%, 5 of 63). Preoperative, operative, and postoperative variables were analyzed retrospectively with regard to early and late mortality. RESULTS: Thirty-day mortality was 11.1% (7 of 63). No strokes occurred. Incidence of renal failure, respiratory failure, and bleeding was 6% (4 of 63), 23% (15 of 63), and 6% (4 of 63), respectively. Mean time from initial repair to reoperation was 69 months (range, 1 to 258). Procedure performed (root versus ascending/resuspension) at initial repair did not affect the time to reoperation (p > 0.05). Median follow-up was 40 months; and 1-, 5-, and 10-year survival was 82%, 74%, and 62%, respectively. Multivariate predictors of late mortality were prior coronary artery bypass graft surgery (odds ratio = 6.5, p < 0.003), bypass time (odds ratio = 3.6, p < 0.02), and renal dysfunction (odds ratio = 3.7, p < 0.05). CONCLUSIONS: Proximal reoperations for repaired acute type A aortic dissection can be performed with acceptable early and late mortality. The concern for proximal reoperation should not dictate the initial procedure choice during acute type A aortic dissection. Continued clinical and radiographic surveillance of repaired type A aortic dissection is warranted.

Update on outcomes of acute type B aortic dissection.

BACKGROUND: The optimal treatment of acute type B aortic dissection remains controversial. This study reports early clinical outcomes of medical management for acute type B aortic dissection. METHODS: Between January 2001 and April 2006, data on 159 consecutive patients (55 women [35%]) with the confirmed diagnosis of acute type B aortic dissection were prospectively collected and analyzed. Mean age was 62 years (range, 29 to 94). On admission, all patients were initiated on an acute type B aortic dissection protocol with the intent to manage all patients medically. Indications for surgical intervention included rupture, aortic expansion, retrograde dissection, malperfusion (visceral, peripheral), and intractable pain. All patients were followed up after discharge with serial clinical and radiographic examinations. RESULTS: Overall hospital mortality was 8.8% (14/159): 17% (4/23) with procedural intervention, and 7.4% (10/136) when medical management was maintained. Early intervention was required in 23 patients (14.5%), of which 21 (13.2%) were open vascular/aortic procedures, and two (1.3%) were percutaneous aortic interventions. Morbidity included rupture (5.0%), stroke (5.0%), paraplegia (8.2%), bowel ischemia (5.7%), acute renal failure (20.1%), dialysis requirement (13.8%), and peripheral ischemia (3.8%). Mortality associated with complicated dissection (74/159) was 17%, and mortality associated with uncomplicated dissection (85/159) was 1.2% (p < 0.0003). Late vascular related procedures were performed in 11 (7.6%) of 144 cases (9 aortic, 2 peripheral vascular). The only independent risk factors for hospital mortality by multiple logistic regression analysis was rupture (p < 0.0009). Independent risk factors for mid-term death were history of chronic obstructive pulmonary disease (p < 0.002) and glomerular filtration rate at admission (p < 0.0001). CONCLUSIONS: Medical management, especially for uncomplicated acute type B aortic dissection, is associated acceptable outcomes. This study provides current data for initial medical management of acute type B aortic dissection. Alternative strategies for the treatment of acute Type B aortic dissection should be compared with these results.

Acute type A aortic dissection complicated by stroke: can immediate repair be performed safely?

OBJECTIVE: Emergency surgical intervention for acute type A aortic dissection complicated by stroke remains controversial. The urgency of immediate repair in this setting is tempered by the concern that cerebral reperfusion may worsen neurologic outcome. The purpose of this study was to report and analyze our results with acute type A aortic dissection complicated by stroke. METHODS: Between September 1999 and March 2005, 151 consecutive patients presented with acute type A aortic dissection. Of this group, 16 (10.6%) patients had sustained a preoperative stroke. Mean age was 56 years (range 43-73 years), with 6 (38%) women. Right hemispheric, left hemispheric, and bilateral strokes occurred in 81%, 13%, and 6%, respectively. Computed tomographic scan or transesophageal echocardiography diagnosed aortic dissection; clinical examination, computed tomographic scan, or transcranial Doppler ultrasound diagnosed stroke. Aortic repair was performed with cardiopulmonary bypass, profound hypothermic circulatory arrest, and retrograde cerebral perfusion. One patient with complete neurologic devastation (coma) was not operated on. RESULTS: Overall hospital mortality was 18.8% (3/16). Mortality in 2 patients who did not undergo surgery (1 patient who was neurologically devastated, and 1 patient whose aorta ruptured while awaiting surgery) was 100% (2/2). Operative mortality was 7% (1/14). Among patients undergoing surgery, neurologic status completely recovered in 2 (14%) patients, improved in 6 (43%) patients, remained the same in 6 (43%) patients, and worsened in none. Median time from onset of stroke to surgery was 9 hours (range 1-240 hours). Eighty percent of patients who underwent surgical repair within 10 hours had improvement in neurologic status, where as none operated on beyond 10 hours improved (P < .02). CONCLUSIONS: In our experience, surgical repair of acute type A aortic dissection can be performed in the setting of preoperative stroke with acceptable mortality. Moreover, no worsening of neurologic condition was observed after surgical repair. Immediate surgical repair is warranted even if acute type A aortic dissection is complicated by stroke.

Outcomes of medical management of acute type B aortic dissection.

BACKGROUND: Currently, the optimal treatment of acute type B aortic dissection remains controversial. The purpose of this study was to report early clinical outcomes of medical management for acute type B aortic dissection. METHODS AND RESULTS: Between January 2001 and March 2005, 129 consecutive patients with the confirmed diagnosis of acute type B aortic dissection were studied. Mean age was 61 years (range, 29 to 94), with 33.3% (43/129) female. Acute type B aortic dissection protocol was instituted with the intent to manage all patients medically. Indications for surgical intervention included rupture, aortic expansion, malperfusion, and intractable pain. All patients were followed-up after discharge. Hospital mortality was 10.1% (13/129), 19% (4/21) when vascular intervention was required, and 8.3% (9/108) when medical management was maintained. Early intervention was required in 21 cases (16.2%), 19 (14.7%) open vascular/aortic cases and 2 cases (1.6%) of percutaneous aortic interventions. Morbidity included rupture (4.7%), stroke (4.7%), paraplegia (8.5%), bowel ischemia (7%), acute renal failure (21%), dialysis requirement (13%), and peripheral ischemia (4.7%). Late vascular-related procedures were performed in 5.2% (6/116) of cases. Univariate risk factors for early mortality were rupture (P<0.0001), need for laparotomy (P<0.008), acute renal failure (P<0.0001), need for dialysis (P<0.0001), and lower extremity ischemia (P<0.0004). The only independent risk factors for hospital mortality by multiple logistic regression was rupture (P<0.0009), and independent risk factors for midterm death were history of chronic obstructive pulmonary disease (P<0.002) and low glomerular filtration rate (<57 mL/min; P<0.0001). CONCLUSIONS: Medical management for acute type B aortic dissection is associated acceptable outcomes. Outcomes of other management strategies, eg, endovascular stenting, for acute type B aortic dissection need to be compared with these results.

Robotic replacement of the descending thoracic aorta: an alternative to endovascular therapy?

BACKGROUND: : Replacement of the descending thoracic aorta is traditionally performed via a left thoracotomy. Endovascular treatment of descending thoracic aortic aneurysms has recently evolved as an alternative treatment for selected patients, yet no long-term results are available. The authors replaced the descending thoracic aorta in a group of pigs with an interposition Dacron graft using a closed-chest, totally robotic technique. METHODS: : Ten pigs, weighing 25 to 45 kg, underwent surgery using the DaVinci robotic surgical system. Under single-lung ventilation and CO2 insufflation, the descending thoracic aorta was completely mobilized. Proximal and distal cross-clamps were applied through separate accessory stab wounds. The mid-descending thoracic aorta was excised. An interposition Dacron graft was robotically sewn in an end-to-end fashion to the descending thoracic aorta using interrupted nitinol clips. RESULTS: : All animals survived the procedure. Mean aortic clamp time was 55 ± 14 minutes. All anastomoses were completed without difficulty with a mean total anastomotic time of 42 ± 11 minutes. The anastomoses were challenged for bleeding by administrating α1-adrenergic receptor agonists to a systolic blood pressure of 200 mm Hg with no evidence of leak. DISCUSSION: : Robotic replacement of the thoracic aorta is feasible and reproducible. This procedure provides the standard Dacron graft repair with its known long-term results. The added value of robotic technology to the therapeutic armamentarium in the treatment of thoracic aortic aneurysms may be worth the effort required for procedural development. Furthermore, it may serve as a valid alternative to endovascular treatment of thoracic aortic aneurysms.

Evolution of risk for neurologic deficit after descending and thoracoabdominal aortic repair.

BACKGROUND: Cross-clamp time has been reported to correlate with risk of neurologic deficit after thoracoabdominal aortic aneurysm repair. Introduction of cerebrospinal fluid drainage and distal aortic perfusion (adjunct) has greatly reduced the incidence of neurologic deficit. We reevaluated the effect of cross-clamp time before and after introduction of adjunct during a 13-year period. METHODS: Between 1991 and 2004, we repaired 1,106 thoracic and thoracoabdominal aortic aneurysms. Four hundred one patients were female and 705 were male (median age, 67 years). Selective use of adjunct was begun in late 1992, with its routine use by 1993. RESULTS: Aortic cross-clamp times have increased significantly (34 seconds/year; p < 0.0001) since 1991. Despite this increase in cross-clamp time, neurologic deficit rates have declined from the first to the fourth quartile (p < 0.02). This decrease in neurologic deficit is most pronounced with the extent II thoracoabdominal aortic aneurysms (21.1% to 3.3%). The use of the adjunct increased the cross-clamp time by a mean of 12 minutes (p < 0.0001), but was associated with a significant protective effect against neurologic deficit (odds ratio = 0.4; p < 0.0002). Although other previously established risk factors remained significantly associated with neurologic deficit, cross-clamp time is no longer significant. CONCLUSIONS: Adjunct significantly reduced the risk of neurologic deficit, despite increasing cross-clamp time. The use of the adjunct appears to blunt the effect of the cross-clamp time and may provide the surgeon the ability to operate without being hurried. Because cross-clamp time has been effectively eliminated as a risk factor with the use of the adjunct, using this variable to construct risk models becomes irrelevant in our experience.

Descending thoracic aortic aneurysm repair: 12-year experience using distal aortic perfusion and cerebrospinal fluid drainage.

BACKGROUND: The benefit of distal aortic perfusion and cerebrospinal fluid drainage over the "clamp and sew" technique during repairs of the descending thoracic aorta is still being debated. The purpose of this report is to analyze our experience with regard to neurologic deficit (paraplegia and paraparesis) and mortality using the adjuncts of distal aortic perfusion and cerebrospinal fluid drainage. METHODS: Between February 1991 and September 2004, we repaired 355 descending thoracic aortic aneurysms. Excluded from analysis were 29 patients who required profound hypothermic circulatory arrest as a result of transverse arch involvement and 26 patients with aortic rupture, leaving a group of 300 patients for which outcomes were analyzed. Mean patient age was 67 years, and 102 (34%) of the patients were women. The adjunct group of distal aortic perfusion and cerebrospinal fluid drainage used in 238 (79.3%) patients was compared with a group of 62 patients who underwent simple cross-clamp with or without the addition of a single adjunct. Multivariable data were analyzed by Cox regression. RESULTS: The incidence of neurologic deficit after all repairs was 2.3% (7 of 300 patients). The incidence of neurologic deficit (immediate and delayed) in the adjunct group was 1.3% (3 of 238 patients), and in the nonadjunct group was 6.5% (4 of 62 patients; p < 0.02). One case of delayed paraplegia occurred in each group. All neurologic deficits occurred in patients with aneurysmal involvement of the entire descending thoracic aorta (extent C; p < 0.02). Statistically significant predictors for neurologic deficit were the use of the adjunct (odds ratio [OR], 0.19; p = 0.02), previous repaired abdominal aortic aneurysm (OR, 7.0; p = 0.005), type C aneurysm (OR, 13.73; p = 0.02), and cerebrovascular disease history (OR, 4.7; p < 0.03). Thirty-day mortality was 8% (24 of 300 patients). Significant multivariate predictors of 30-day mortality were preoperative renal dysfunction (OR, 4.6; p < 0.01) and female sex (OR, 2.9; p < 0.03). CONCLUSIONS: Repairs of the descending thoracic aorta using the adjunct of distal aortic perfusion and cerebrospinal fluid drainage can be performed with a low incidence of neurologic deficit and an acceptable mortality. The use of the adjuncts should be considered during elective repairs of the descending thoracic aorta.