Open Thoracoabdominal Aortic Aneurysm Repair.

Operative techniques and perioperative management for thoracoabdominal aortic aneurysm (TAAA) have been modified and refined, but the morbidity and mortality remain high. Major challenges in open TAAA repair are prevention of ischemic insults to multiple organs, especially the spinal cord, and minimizing bleeding. The purpose of this narrative review is to provide currently available techniques and management strategies for open TAAA repair that optimize outcomes.

Open Treatments for Thoracoabdominal Aortic Aneurysm Repair.

Thoracoabdominal aortic aneurysms (TAAA) represent a unique pathology that is associated with considerable mortality if untreated. While the advent of endovascular technologies has introduced new modalities for consideration, the mainstay of TAAA treatment remains open surgical repair. However, the optimal conduct of open TAAA repair requires careful consideration of patient risk factors and a collaborative team effort to mitigate the risk of perioperative complications. In this chapter, we briefly outline the history of treating TAAA, preoperative preparation and postoperative care, and our operative techniques for treatment.

Reappraisal of the role of motor and somatosensory evoked potentials during open distal aortic repair.

OBJECTIVE: Intraoperative motor and somatosensory evoked potentials have been applied to monitor spinal cord ischemia during repair. However, their predictive values remain controversial. The purpose of this study was to evaluate the impact of motor evoked potentials and somatosensory evoked potentials on spinal cord ischemia during open distal aortic repair. METHODS: Our group began routine use of both somatosensory evoked potentials and motor evoked potentials at the end of 2004. This study used a historical cohort design, using risk factor and outcome data from our department's prospective registry. Univariate and multivariable statistics for risk-adjusted effects of motor evoked potentials and somatosensory evoked potentials on neurologic outcome and model discrimination were assessed with receiver operating characteristic curves. RESULTS: Both somatosensory evoked potentials and motor evoked potentials were measured in 822 patients undergoing open distal aortic repair between December 2004 and December 2019. Both motor evoked potentials and somatosensory evoked potentials were intact for the duration of surgery in 348 patients (42%). Isolated motor evoked potential loss was observed in 283 patients (34%), isolated somatosensory evoked potential loss was observed in 18 patients (3%), and both motor evoked potential and somatosensory evoked potential loss were observed in 173 patients (21%). No spinal cord ischemia occurred in the 18 cases with isolated somatosensory evoked potential loss. When both signals were lost, signal loss happened in the order of motor evoked potentials and then somatosensory evoked potentials. Immediate spinal cord ischemia occurred in none of those without signal loss, 4 of 283 (1%) with isolated motor evoked potential loss, and 15 of 173 (9%) with motor evoked potential plus somatosensory evoked potential loss. Delayed spinal cord ischemia occurred in 12 of 348 patients (3%) with intact evoked potentials, 24 of 283 patients (8%) with isolated motor evoked potentials loss, and 27 of 173 patients (15%) with motor evoked potentials + somatosensory evoked potentials loss (P < .001). Motor evoked potentials and somatosensory evoked potentials loss were each independently associated with spinal cord ischemia. For immediate spinal cord ischemia, no return of motor evoked potential signals at the conclusion of the surgery had the highest odds ratio of 15.87, with a receiver operating characteristic area under the curve of 0.936, whereas motor evoked potential loss had the highest odds ratio of 3.72 with an area under the curve of 0.638 for delayed spinal cord ischemia. CONCLUSIONS: Somatosensory evoked potentials and motor evoked potentials are both important monitoring measures to predict and prevent spinal cord ischemia during and after open distal aortic repairs. Intraoperative motor evoked potential loss is a risk for immediate and delayed spinal cord ischemia after open distal aortic repair, and somatosensory evoked potential loss further adds predictive value to the motor evoked potential.

Multiple Interventions to Thoracoabdominal Aortic Aneurysm in a Child With Tuberous Sclerosis.

Thoracoabdominal aortic aneurysms in toddlers are extremely rare. However, we experienced an extent III thoracoabdominal aortic aneurysm in a boy with tuberous sclerosis who underwent 3 open repairs and 1 endovascular aortic repair between the ages of 4 years and 18 years. This case highlights the potential for severe recurrent vascular aneurysms in the thoracic and abdominal aorta as a complication of tuberous sclerosis in children. Although aortic aneurysms in children are rare, it is vital to recognize these cases to prevent death due to rupture.

Atrial Fibrillation Ablation-induced Pulmonary Venous Occlusion Requiring Pneumonectomy.

A 71-year-old woman with a history of atrial fibrillation underwent a catheter-based ablation procedure. Months later, she presented with dyspnea and a left-sided pleural effusion. Diagnostic evaluation revealed left-sided pulmonary venous occlusion, with essentially absent left lung perfusion. The patient underwent left pneumonectomy, with left atrial appendage occlusion. Although lobectomy for pulmonary venous occlusion of a single vein after pulmonary vein isolation has been described, this appears to be a novel report of occluded pulmonary venous drainage of an entire lung necessitating pneumonectomy.

Deep Hypothermic Circulatory Arrest With Retrograde Cerebral Perfusion: How Long Is Safe?

BACKGROUND: Cerebral protection strategies during proximal aortic repair remains controversial due to lack of evidence and large patient cohort studies. We herein evaluated our 3-decade experience using hypothermic circulatory arrest with retrograde cerebral perfusion (DHCA/RCP) to evaluate for its safety and safe duration during proximal aortic repair. METHODS: All proximal aortic repairs using DHCA/RCP from January 1991 to December 2020 performed at our institution were included in the analyses. Perioperative variables were evaluated for mortality and cerebrovascular accident (CVA; combined stroke and transient ischemic attack). RESULTS: In all, 1429 repairs were performed using DHCA/RCP. Of these, 464 (32%) were acute aortic dissection and 297 (21%) were resternotomy. The median age was 61 years (interquartile range 50-70 years). Operative mortality was 8.9% and CVA occurred in 8.4% (stroke 7.8%, transient ischemic attack 0.6%). There was a linear relationship between the RCP time and the incidence of immediate postoperative CVA. Incidence of CVA was less than 5% when RCP time was less than 20 minutes, 6.3% at 30 minutes, and 11.5% at 60 minutes. Multivariable analysis demonstrated acute type A aortic dissection (odds ratio 2.58, 95% CI1.49-4.48, P = .001) was the only predictor for postoperative CVA but RCP time was not (odds ratio 0.991, 95% CI 0.962-1.02, P = .527). CONCLUSIONS: DHCA/RCA provided satisfactory outcomes after proximal aortic operations. The safe duration of RCP with DHCA was up to 30 minutes in our experience. When the circulatory arrest time is expected to exceed 60 minutes, other adjuncts for cerebral protection should be recommended.

Rapid cooling is a safe technique in patients undergoing circulatory arrest for aortic repair.

Objective: To evaluate our institutional experience with rapid cooling for hypothermic circulatory arrest in proximal aortic repair. Methods: We retrospectively reviewed data from 2171 patients who underwent proximal aortic surgery requiring hypothermic circulatory arrest between 1991 and 2020. Cooling times were divided into quartiles and clinical outcome event rates were compared across quartiles using contingency table methods. Incremental effect of cooling time was assessed in the context of other perfusion time variables using multiple logistic regression analysis. Results: Median age was 61 years (interquartile range, 49-70 years) and 34.1% of patients were women. The procedure was emergent in 33.5% of patients, 22.9% had a previous sternotomy. The median circulatory arrest time was 22 minutes, with retrograde cerebral perfusion used in 94% of cases. Median cardiopulmonary bypass time was 149 minutes, with an aortic crossclamp time of 90 minutes. Patients were cooled to deep hypothermia. The first quartile had cooling times ranging from 5 to 13 minutes, second 14 to 18 minutes, third 19-23 minutes, and fourth 24-81 minutes. Overall, 30-day mortality was 9.4%, and was not significantly different across quartiles. There was a statistically significant trend toward lower rates of postoperative encephalopathy, gastrointestinal complications, and respiratory failure with shorter cooling times (P < .001, .006, and < .001, respectively). There was no significant difference in rates of postoperative stroke or dialysis. Conclusions: Rapid cooling can be performed safely in patients undergoing aortic surgery requiring circulatory arrest without increasing mortality or stroke. There were significantly lower rates of coagulopathy, respiratory failure, and postoperative encephalopathy with shorter cooling times.

Extensive cell salvage and postoperative outcomes following thoracoabdominal and descending aortic repair.

OBJECTIVE: Cell salvage (CS) reduces intraoperative blood transfusion. However, it may cause deformity of the red blood cells and loss of coagulation factors, which may lead to unwanted sequelae. Thus, we hypothesized that extensive CS would lead to adverse outcomes after descending/thoracoabdominal aortic aneurysm (D/TAAA) repair. METHODS: Between 1991 and 2017, 2012 patients undergoing D/TAAA repair were retrospectively reviewed. After we excluded patients without reported intraoperative CS amount, patients were enrolled in the study (N = 1474) and divided into 2 groups: low CS (salvaged units <40, N = 983) and high CS (salvaged units ≥40, N = 491). Analyses were performed to verify the extensive CS as the risk factor for adverse outcomes. RESULTS: Preoperative demographics showed that the high-CS group had a significantly greater incidence of male patients (72% vs 58%), heritable aortic disease (24% vs 17%), redo (27% vs 20%), greater glomerular filtration rate (mL/min/1.73 m2, 75 vs 66) and more extensive aneurysms (TAAA extent II-IV). The high-CS group had significantly more postoperative complications compared with the low-CS group, including respiratory failure, renal failure, cardiac complications, neurologic deficits, bleeding, and 30-day mortality. Multivariable analysis confirmed high CS was an independent risk factor for renal failure along with long bypass time, older age, and extent of repairs. There was an incremental risk of renal failure and 30-day mortality proportional to salvaged cell unit (P < .001 in both). CONCLUSIONS: Increased salvaged cell units were associated with adverse postoperative outcomes after D/TAAA repairs. Risk of renal failure and mortality increased proportionally to the salvaged cell units.

In-hospital outcomes and long-term survival of women of childbearing age with aortic dissection.

OBJECTIVE: In the present study, we defined the outcomes and effects of pregnancy in a cohort of women of childbearing age with acute aortic dissection (AAD). METHODS: We reviewed our database of AAD to identify all eligible female patients. Women aged <45 years were included. Data on pregnancy timing with respect to the occurrence of dissection, the demographic data, dissection extent, dissection treatment, dissection-related outcomes, overall maternal and fetal mortality, and genetic testing results were analyzed. RESULTS: A total of 62 women aged <45 years had presented to us with AAD from 1999 to 2017. Of the 62 women, 37 (60%) had had a history of pregnancy at AAD. Of these 37 patients, 10 (27%) had had a peripartum aortic dissection, defined as dissection during pregnancy or within 12 months postpartum. Of the 10 AADs, 5 were type A and 5 were type B. Three patients had presented with AAD during pregnancy (one in the second and two in the third trimester). Five patients (50%) had developed AAD in the immediate postpartum period (within 3 months) and two (20%) in the late postpartum period. For the immediate postpartum AADs (<3 months), four of the five patients delivered via cesarean section. Of these 10 peripartum AADs, 3 (30%) had occurred in patients with known Marfan syndrome. In-hospital mortality for those with peripartum AAD was 10% (1 of 10). Fetal mortality was 20% (2 of 10). CONCLUSIONS: The frequency of aortic dissection in women of childbearing age at our institution was low. However, pregnancy might increase the risk of those young women genetically predisposed to dissection events. From these data, this risk appears to be greatest in the immediate postpartum period, even for those who undergo cesarean section. Close clinical and radiographic surveillance is required for all women with suspected aortopathy, especially in the third trimester and early postpartum period.

Open thoracoabdominal aortic aneurysm surgery technique: how we do it.

More than four decades have passed since the modern principals to treat thoracoabdominal aortic aneurysm (TAAA) have been established. The historical challenges in repair of TAAA are represented by - and continue to be - multiorgan protection. Among all organs, the spinal cord remains one of the most vital and vulnerable. We described our current techniques of open extent II TAAA repair, including the following topics: anesthesia, intraoperative monitoring, skin incision, exposure of the TAAA, left heart bypass, graft replacement technique, intercostal artery reattachment, visceral/renal artery reconstructions, and postoperative care. We use cerebrospinal fluid drainage, distal aortic perfusion, mild passive hypothermia, sequential clamping, and visceral and renal perfusion using roller pump in all the cases for multiorgan protection. Both motor-evoked potentials and somatosensory-evoked potentials ere used to guide the conduct of intercostal artery reattachment. Our group demonstrated that the use of adjuncts has reduced the overall spinal cord ischemia rate after Extent I TAAA from 15% to less than 2% and after Extent II TAAA from 33% (50% with clamp time exceeding 40 minutes in "clamp and go" era) to less than 4%. The current standard practice of TAAA repair with adjuncts has improved outcomes, especially regarding spinal cord ischemia.

A history of open thoracoabdominal aortic aneurysm repair: perspective from Houston.

As late as the early 1950s, ligation, cellophane wrapping, endoluminal wiring, endoaneurysmorrhaphy, and other techniques were well-accepted treatments for aneurysm. Techniques aimed at repair of syphilitic and saccular aneurysms of the proximal aorta were largely unsuitable for the larger, fusiform atherosclerotic aneurysms of the thoracoabdominal aorta. The earliest replacements of the thoracoabdominal aorta relied on the use of donor homografts. Repair of thoracoabdominal aortic aneurysms (TAAAs) necessitated exposing the thoracic aorta above the diaphragm and the abdominal aorta below the diaphragm. Furthermore, these repairs were complicated by incorporating the branching visceral arteries, as well as the risk of life-threatening distal ischemia during repair. Although many of the early centers for aortic surgery were able to quickly develop aortic banks to prepare and store homografts, in time, it became clear that homografts were not ideal for aortic replacement. The ideal aortic replacement would be nontoxic, hypoallergenic, durable, elastic, pliable, and readily available in multiple sizes and shapes. Although Vinyon-N and other materials were explored as synthetic aortic substitutes, ultimately Dacron (Dacron, Kennesaw, GA, USA) was determined to be the most suitable material for aortic graft replacement. The success of Dacron ushered in extra-anatomic approach to TAAA repair, which remained popular for 2 decades. In time, the graft inclusion technique (which followed an anatomical approach) was adopted, which facilitated shorter repair times and improved outcomes for patients. rotective adjuncts-such as left heart bypass, cerebrospinal fluid drainage, and cold renal perfusion-were incorporated into surgical repair; the historical context of these adjuncts is explored in depth. The success of TAAA repair depends on the contributions of many individuals. The history of TAAA repair continues to evolve and remains indebted to the pioneering heroes, without whom, successful repair would not be possible.

Outcomes of open repairs of chronic distal aortic dissection anatomically amenable to endovascular repairs.

OBJECTIVE: To review short-term outcomes and long-term survival and durability after open surgical repairs for chronic distal aortic dissections in patients whose anatomy was amenable to thoracic endovascular aortic repair (TEVAR). METHODS: Between February 1991 and August 2017, we repaired chronic distal dissections in 697 patients. Of those patients, we enrolled 427 with anatomy amenable to TEVAR, which included 314 descending thoracic aortic aneurysms (DTAAs) and 105 extent I thoracoabdominal aortic aneurysms (TAAAs). One hundred eighty-five patients (44%) had a history of type A dissection, and 33 (7.9%) had a previous DTAA/TAAA repair. Variables were assessed with logistic regression for 30-day mortality and Cox regression for long-term mortality. Time-to-event analysis was performed using Kaplan-Meier methods. RESULTS: Thirty-day mortality was 8.4% (n = 36). In all, 22 patients (5.2%) developed motor deficit (paraplegia/paraparesis), and 17 (4.0%) experienced stroke. Multivariable analysis identified low estimated glomerular filtration rate (eGFR; <60 mL/min/1.73 m2), previous DTAA/TAAA repair, and chronic obstructive pulmonary disease (COPD) as associated with 30-day mortality. Patients without all 3 risk factors had a 30-day mortality rate of 2.6%. During a median follow-up of 6.5 years, 160 patients died. The survival rate was 81% at 1 year and 61% at 10 years. Cox regression analysis identified preoperative aortic rupture, eGFR <60 mL/min/1.73 m2, previous DTAA/TAAA repair, COPD, and age >60 years as predictive of long-term mortality. Forty-five patients required subsequent aortic procedures, including 8 reinterventions to the treated segment. Freedom from any aortic procedures was 85% at 10 years, and aortic procedure-free survival was 45% at 10 years. Hereditary aortic disease was the sole predictor for any aortic interventions (hazard ratio, 3.2; P = .004). CONCLUSIONS: Open surgical repair provided satisfactory low neurologic complication rates and durable repairs in chronic distal aortic dissection. Patients without low eGFR, redo, and COPD are the low-risk surgical candidates and may benefit from open surgical repair at centers with similar experience to ours. Patients with hereditary aortic disease warrant close surveillance.

Resection and replacement of thoracic aortic graft infections.

OBJECTIVES: Thoracic aortic graft infection (TAGI) presents a formidable challenge with high mortality. We evaluated our 22-year experience managing TAGI with extensive debridement, graft replacement, vascularized tissue coverage, and aggressive antibiotics. METHODS: We reviewed all consecutive patients with TAGI from 1991 to 2013. We also compared infected cases versus noninfected reoperative controls using a case-control design. Standard statistical methods were used for descriptive analysis, and Kaplan-Meier for survival analysis. RESULTS: We treated 32 TAGI patients, involving 19 ascending/arch (A/A) and 13 descending/thoracoabdominal (D/TAA) grafts, including 4 endografts. In total, 19 (59.4%) presented with pseudoaneurysm and 11 (34.4%) with aortic fistula. Vascularized tissue (omentum or muscle) coverage was possible in 22 (71.0%) patients. Thirty-day mortality occurred in 3 (9.4%) patients, with no 30-day mortality among those receiving vascularized graft coverage (P = .018). During follow-up, reinfection occurred in 8 patients (25% [4 A/A and 4 D/TAA]). Five-year overall (A/A 45.4% vs D/TAA 28.9%, P = .434) and reinfection-free (A/A 19.2%, D/TAA 27%, P = .409) survival was similar between groups. Long-term mortality was greater after endograft infection (100% vs 25% at 2.5 months, P = .0007) or aortobronchial fistulization (100% vs 37.9% at 6 months, P = .026). Time to reintervention was shorter in infected versus non-infected reoperative cases (31 vs 83 months, P < .0001), but there were no significant differences in long-term mortality after reoperation. CONCLUSIONS: TAGI continues to represent a highly morbid surgical challenge. Prompt antimicrobial coverage, debridement, graft replacement, and vascularized graft coverage, yielded best long-term results. Endograft infection and aortobronchial fistula had very poor prognoses.

Treatment of an Infected, Bovine Pericardial Carotid Patch: Excision and Reconstruction with a Superficial Femoral Arterial Interposition Graft.

Carotid patch infection is a rare complication but one often associated with severe morbidity, including hemorrhage, stroke, cranial nerve injury, and mortality. We present a case of a gram-negative bacterial infection of a bovine pericardial carotid patch. Treatment ultimately required patch explantation and reconstruction with a femoral arterial interposition graft.

Clinically Important Misclassification of Aortic Valve Stenosis Severity Using Non-Invasive Techniques: Simultaneous Echocardiography and Cardiac Catheterization During Transcatheter Aortic Valve Implantation in Awake Patients.

BACKGROUND: Suitability for transcatheter aortic valve (AV) implantation (TAVI) is determined by using transthoracic echocardiography (TTE), although left-sided cardiac catheterization (LCC) provides directly measured pressure data. TAVI in awake patients permits simultaneous comparison of TTE and LCC under physiologically relevant left ventricular loading conditions. We hypothesized that clinically important discrepancies between TTE and LCC would be identified. METHODS AND RESULTS: TAVI was performed in 108 awake patients undergoing intra-procedural TTE and LCC between January 1, 2016 and December 31, 2016, based upon pre-procedure TTE data. Intra-procedural assessments simultaneously were performed before and after prosthesis implantation. Based upon mean trans-AV systolic ejection pressure gradient (MSEPG), AS was graded as: mild (<20 mm Hg; grade 1), moderate (20 - <40 mm Hg; grade 2), or severe (≥40 mm Hg; grade 3). In 79 of the 108 (73.1%) patients, intra-procedural TTE and LCC assessments were concordant. In 2 of the 108 (1.9%) patients, TTE overestimated AS severity by ≥1 grade. In 27 of the 108 (25.0%) patients, TTE underestimated AS severity by ≥1 grade. In total, AS severity reclassification occurred in 29 (26.9%) patients. Overall, TTE underestimated MSEPG by 8.9 ± 1.2 mm Hg (TTE MSEPG versus LCC MSEPG; P < .001). CONCLUSION: Current TTE criteria appear to frequently and importantly underestimate AS severity. Because decision-making regarding TAVI often exclusively is based upon TTE data, these findings suggest either a continued role for LCC in the diagnostic assessment of AS in patients who do not meet standard TTE criteria or lowering TTE cutoffs for TAVI.

Feasibility and Durability of the Modified Cabrol Coronary Artery Reattachment Technique.

BACKGROUND: This study evaluated the feasibility and durability of the modified Cabrol coronary reattachment technique after aortic root replacement. METHODS: The study retrospectively reviewed 370 patients who underwent aortic root replacement, during 1991 and 2018, and who were separated into 2 groups: a modified Carol (mCabrol) group (n = 84), consisting of patients with 1 or both coronary ostia reimplanted using a modified Cabrol technique; and a Carrel group (n = 286), consisting of patients with both coronary ostia reimplanted using the Carrel button technique. RESULTS: Baseline characteristics were similar in the 2 groups, except the mCabrol group had higher rates of redo sternotomy (74% vs 16%), chronic aortic dissection (58% vs 19%), and infection (14% vs 3%). In the mCabrol group, 60% had both coronary arteries reattached with the technique, and 40% of the procedures were unilateral. Operative mortality was significantly higher in mCabrol group compared with the Carrel group. However, in the stratified analysis for resternotomy, operative mortality between 2 groups were similar (16% vs 13%; P = .786). The survival rate at 5 years and 10 years was 68 ± 6% and 44 ± 6%, respectively, in the mCabrol group and 87 ± 2% and 80 ± 3%, respectively, in the Carrel group (log-rank P < .001). After propensity adjustment, chronic kidney disease and prior coronary artery bypass grafting, but not the modified Cabrol technique, were independent predictors of both operative mortality and follow-up mortality (operative, P = .518; follow-up, P = .080). A total of 47 (66%) of 71 discharged patients in the mCabrol group had follow-up imaging, and no Cabrol graft was occluded. Two patients in the mCabrol group required interventions related to the reattachment technique: 1 coronary ostial anastomosis stenosis and 1 graft-to-graft anastomosis pseudoaneurysm. CONCLUSIONS: The modified Cabrol reattachment technique was not predictive of increased mortality and has excellent patency.

Coil embolization of a ruptured gastroduodenal artery pseudoaneurysm presenting with hemosuccus pancreaticus.

Hemosuccus pancreaticus is a rare form of upper gastrointestinal bleeding that accounts for roughly 1 in 1500 cases. It is characterized by hemorrhage from the ampulla of Vater secondary to rupture of a peripancreatic pseudoaneurysm or visceral artery pseudoaneurysm. Among the visceral artery pseudoaneurysms, gastroduodenal artery pseudoaneurysms are among the rarest. In this case report, we describe a successful coil embolization of a large ruptured gastroduodenal pseudoaneurysm in a patient with massive gastrointestinal bleeding.

Propensity and impact of autologous platelet rich plasma use in acute type A dissection.

BACKGROUND: Coagulopathy in patients undergoing open repair of acute type A aortic dissection using cardiopulmonary bypass and hypothermic circulatory arrest is a common complication. Autologous platelet rich plasma is an intraoperative blood conservation technique, which has been shown in previous studies to promote hemostasis, leading to a reduction of blood product transfusions during elective aortic surgery. The purpose of this study is to evaluate the effectiveness of autologous platelet rich plasma as a blood conservation technique during open surgical repair of acute type A aortic dissection. METHODS: We reviewed all acute type A aortic dissection cases using hypothermic circulatory arrest, excluding patients presenting in extremis. Perioperative transfusion requirements and clinical outcomes were analyzed. The end points analyzed included early mortality, postoperative stroke, renal dysfunction, prolonged ventilation, coagulopathy, and length of postoperative intensive care unit stay. Parsimonious and saturated propensity scores were calculated for platelet rich plasma use, and all outcomes were propensity adjusted. RESULTS: Between 2003 and 2014, 85 of 391 acute type A aortic dissection repairs used autologous platelet rich plasma. Mean age of patients was 58 ± 15 years, and 70% were male. Obstructive sleep apnea (22% vs 13%, P = .04) and baseline ejection fraction (57% ± 6.7% vs 55% ± 10%; P = .014) were higher in the autologous platelet rich plasma group. Intraoperative propensity-adjusted blood products, 2 units fewer packed red blood cells (P = .001), 4 units fewer fresh-frozen plasma (P = .001), 6 units fewer platelets (P = .001), 1.3 units fewer cell-savers (P = .002), and 5 units fewer cryoprecipitate (P = .001) were significantly reduced by autologous platelet rich plasma use. Significant unadjusted reduction in postoperative reoperation for bleeding (8% vs 17%, P = .046) after autologous platelet rich plasma was reported, although propensity adjustment eliminated significance (P = .079). No difference in stroke, cardiac, or renal complications was observed. Postoperative transfusion needed during the first 3 days was significantly reduced in the autologous platelet rich plasma group: 2 units fewer packed red blood cells (P = .13), 2 units fewer fresh-frozen plasma (P = .018), and 5 units fewer platelets (P = .001), when compared with those without autologous platelet rich plasma. Ventilation time was reduced by 3 days (P = .002), and intensive care length of stay was reduced by 3 days (P = .063) after intraoperative autologous platelet rich plasma use. CONCLUSIONS: The use of autologous platelet rich plasma in patients undergoing open repair of acute type A aortic dissection was associated with a reduction in intraoperative and postoperative blood transfusions, as well as decreased early postoperative morbidity.

Intraoperative Intercostal Nerve Cryoanalgesia Improves Pain Control After Descending and Thoracoabdominal Aortic Aneurysm Repairs.

BACKGROUND: We reviewed the efficacy of intraoperative intercostal nerve cryoanalgesia for pain control in patients undergoing descending and thoracoabdominal aortic aneurysm repairs. METHODS: During 2013 and 2017, 241 patients underwent descending and thoracoabdominal aortic aneurysm repair. Of those, 38 patients were treated with intraoperative cryoanalgesia to the intercostal nerves at the level of 4th to 10th under electromyography guidance and were compared with patients who did not receive cryoanalgesia. Both groups received multilevel paravertebral block and local infiltration with liposomal bupivacaine. Numerical pain scale scores and amount of opioid usage in morphine milligram equivalences on the first to fourth and eighth postoperative days were collected. We excluded patients from the study who were extubated after the third postoperative day or who were reintubated. RESULTS: One hundred twenty-six patients met the inclusion criteria: 28 in the cryoanalgesia group and 98 in the control group. Preoperative patient demographics were similar in both groups, except for more frequent chronic dissection in patients with cryoanalgesia (93% vs 65%, P = .004). Postoperative major complications, length of stay, and discharge to home were not significantly different in either group. However, median ventilation hours were significantly shorter in the cryoanalgesia group (5 vs 12 hours, P < .001). Opioid use was significantly less in the cryoanalgesia group after postoperative day 4. Indexed morphine milligram equivalences, adjusted with body surface area, and numerical pain scale scores were significantly lower in the cryoanalgesia group throughout the postoperative course. CONCLUSIONS: Intercostal nerve cryoanalgesia under electromyography guidance provided improved pain control and reduced narcotic use after descending and thoracoabdominal aortic aneurysm repairs compared with those who only received paravertebral block.

Impact of redo sternotomy on proximal aortic repair: Does previous aortic repair affect outcomes?

PURPOSE: Proximal aortic repair (AoR) in the setting of previous sternotomy may be associated with greater risk than primary repair. Our objective was to determine whether redo sternotomy increases the risk of adverse outcomes following proximal aortic surgery. METHODS: We reviewed all proximal AoRs from 1991 to 2014. Outcomes were compared between first-time AoR (non-redo = 1305) and redo AoRs, which were further classified into 3 categories: (1) previous acute type A aortic dissection (AAD) repair (redo-AAD = 146, 8.3%); (2) previous proximal aneurysm repair (redo-aneurysm = 165, 9.4%); and (3) previous cardiac (non-aortic) sternotomy (redo-cardiac = 145, 8.2%). Data were analyzed by contingency tables and multiple regression. RESULTS: In total, 456 of 1761 (25.9%) proximal AoRs had redo sternotomy. Aortic redos (redo-AAD and redo-cardiac) had significantly more connective tissue disorders (P < .001). On presentation, AAD was least common in aortic redos followed by cardiac redos (redo-cardiac) versus non-redos (5% vs 28% vs 31%, P < .001). At reoperation, 190 underwent ascending + hemiarch (21% redo-AAD, 50% redo-aneurysm, 53% redo-cardiac), 140 total arch (64% redo-AAD, 15% redo-aneurysm, 15% redo-cardiac), 110 elephant trunk (52% redo-AAD, 12% redo-aneurysm, 11% redo-cardiac), 159 AVR (36% redo-AAD, 42% redo-aneurysm, 25% redo-cardiac), and 100 aortic root (34% redo-AAD, 22% redo-aneurysm, 10% redo-cardiac). Except for pulmonary, redo sternotomy did not increase risk of postoperative complications. Thirty-day mortality after redo sternotomy was 14%-the greatest among cardiac redos. Over a median follow-up of 13 years, non-redos had significantly greater long-term survival (P < .001). Coronary artery disease was a significant predictor of mortality (P < .001). After adjustment for coronary artery disease, cardiac redos had the greatest long-term mortality risk (hazard ratio, 1.43, P < .005). Previous AoR did not significantly add risk above redo sternotomy alone (P = .734). CONCLUSIONS: Redo sternotomy is associated with increased risk for short- and long-term mortality after proximal aortic repair. Despite need for extensive repair, previous proximal aortic (for aneurysm or AAD) repair did not add further risk above that attributable to redo sternotomy.