Retroperitoneal vs. Transperitoneal Approach for Non-Ruptured Open Conversion after Endovascular Aneurysm Repair.

OBJECTIVE: Several studies comparing the transperitoneal (TP) and retroperitoneal (RP) approach for AAA repair suggest that the RP approach may result in lower rates of perioperative mortality and morbidity. However, data comparing these approaches for open conversion are lacking. This study aims to evaluate the association between the type of approach and outcomes following open conversion after EVAR. METHODS: We included all patients who underwent open conversion after EVAR between 2010-2022 in Vascular Quality Initiative (VQI). Patients presenting with rupture were excluded. The primary outcome was perioperative mortality. The secondary outcomes included perioperative complications and 5-year mortality. Inverse probability weighting (IPW) was used to adjust for factors with statistical or clinical significance. Logistic regression was used to assess perioperative mortality and complications in the weighted cohort. 5-year mortality was evaluated using Kaplan-Meier and Cox regression. RESULTS: We identified 660 patients (39% RP) who underwent open conversion after EVAR. Compared with TP, RP patients were older (75 [IQR, 70-79] years vs. 73.5 [IQR, 68-79] years, p<.001), and more frequently had prior myocardial infarction (33% vs. 22%, p=.002). Compared with the TP approach, the RP approach was less frequently used in case of associated iliac aneurysm (19% vs. 27%, p=.026), but more frequently with associated renal bypass (7.8% vs. 1.7%, p<.001) and by high volume physicians (highest quintile, >7 AAA annually: 41% vs. 17%, p<.001) and in high volume centers (highest quintile, >35 AAA annually: 36% vs. 20%, p<.001). RP patients, compared with TP patients, were less likely to have external iliac or femoral distal anastomosis (8.2% vs. 21%, p<.001), and an infrarenal clamp (25% vs. 36%, p<.001). Unadjusted perioperative mortality was not significantly different between approaches (RP vs. TP: 3.8% vs. 7.5%; p=.077). After risk adjustment, RP patients had similar odds of perioperative mortality (aOR, 0.49; 95%CI, 0.22-1.10; p=.082), and lower odds of intestinal ischemia (aOR, 0.26; 95%CI, 0.08-0.86; p=.028) and in-hospital reintervention (aOR, 0.43; 95%CI, 0.22-0.85; p=.015). No significant differences were found in the other perioperative complications, and 5-year mortality (aHR, 0.79; 95%CI, 0.47-1.32; p=.37). CONCLUSIONS: - Our findings suggest that the RP approach may be associated with lower adjusted odds of perioperative complications compared with the TP approach. The RP approach should be considered for open conversion after EVAR when feasible.

An Expert Delphi Consensus on Risk Factors for Adverse Events After Endovascular Aortic Aneurysm Repair: Tier 1 Study From the International RIsk Stratification in EVAR (IRIS-EVAR) Working Group.

PURPOSE: Tier 1 of the International RIsk Stratification in EndoVascular Aneurysm Repair (IRIS-EVAR) project aimed to identify important risk factors for adverse events following endovascular aneurysm repair (EVAR). MATERIALS AND METHODS: Initially, the steering committee proposed a number of risk factors for adverse events following EVAR. A Delphi consensus was performed as expert panelists were presented with risk factors and provided the opportunity to propose additional risk factors during the process. Experts in EVAR completed an online survey via 3 structured rounds. The first round opened in July 2022, and the third round closed in December 2022. Panelists rated risk factors using a 4-point Likert scale. Consensus was defined as >70% of participants agreeing/strongly agreeing or disagreeing/strongly disagreeing with a statement in each round. RESULTS: Thirty-five panelists from 12 countries completed the 3 rounds of surveys. Of a total of 64 individual risk factors assessed by the panelists, 37 (58%) had consensus that they were important for adverse events following EVAR. Risk factors were stratified in 4 domains: 14 (38%) were related to preoperative anatomy, 3 (8%) related to the aortic device selection, 8 (22%) related to the procedure performance, and 12 (32%) related to postoperative surveillance. Factors with the highest consensus in each domain were as follows: proximal aortic neck length <15 mm (98% consensus), anatomy non-compliant with instructions for use (94% consensus), length of achieved proximal aortic neck post implantation <10 mm (98% consensus), and non-satisfactory seal at landing or overlapping zones/sac expansion/kink or stenosis (100% consensus each), respectively. CONCLUSIONS: Clinically important risk factors for adverse events after EVAR were identified via expert consensus. These factors will be used to develop an expert consensus-informed risk stratification and surveillance strategies. CLINICAL IMPACT: This is the first study to apply an in-depth Delphi methodology to achieve an expert consensus on risk factors for adverse events after endovascular aneurysm repair (EVAR). Important risk factors were stratified in 4 domains: preoperative anatomy (14 factors), aortic device (3 factors), EVAR procedure (8 factors), and postoperative surveillance (12 factors). This study will potentially influence future clinical practice by providing evidence informed by experts regarding predictors of adverse events following EVAR that can be taken into account during decision making and developing post-EVAR surveillance strategies. These findings will inform a risk stratification tool for everyday use by vascular surgeons.

Distal Repair After Total Aortic Arch Replacement With Frozen Elephant Trunk in Patients With Chronic Multilevel Thoracic Aortic Disease.

OBJECTIVE: To examine the management of distal aortic disease after total arch replacement with the frozen elephant trunk (TAR + FET) in patients with chronic thoracic aortic disease. METHODS: Two centre retrospective study of consecutive patients treated between January 2010 and December 2019. The primary endpoint was 30 day or in hospital death. The secondary endpoint was midterm survival. Data are presented as median (interquartile range [IQR]). The χ2 or Fisher's exact test was used as appropriate. Estimated survival (standard error) was assessed by calculating the Kaplan-Meier product limit estimator with right censoring of survival data. A p value of < .050 was considered statistically significant. STROBE guidelines were followed. RESULTS: A total of 158 patients (72 men; median age 70 years, IQR 64, 75; median distal aortic diameter 58 mm, IQR 46, 68; 127 aneurysmal disease, 31 chronic dissection) underwent TAR + FET. The peri-operative mortality rate was 10.1% (9/107 elective, 7/51 non-elective). Of 74 (46.8%) patients with a primary distal seal, seven (9.5%) died peri-operatively, the distal seal was maintained during follow up in 51, nine underwent late distal repair (two planned, seven unplanned; one open, eight endovascular; one peri-operative death) with a median interval to unplanned repair of 777 days (IQR 462, 1480), and seven with loss of seal had no intervention. Distal seal failed in 2/28 (7%) patients with a distal seal length > 30 mm and device oversizing > 10%, compared with 12/39 (31%) patients who did not meet these criteria (p = .031). In 84 patients without a primary distal seal, nine (10.7%) died peri-operatively, the distal aorta remained below the size threshold for repair during follow up in 12 patients, 44 had distal repair (median aortic diameter 64 mm, IQR 60, 75; eight open, one hybrid, 35 endovascular repairs; no deaths) at a median of 256 days (IQR 135, 740), and 19 did not have distal repair at the end of the follow up period: six died before planned repair at a median interval of 115 days (IQR 85, 120); eight were considered unfit; one was assessed as fit but declined; and four patients were awaiting assessment. Median follow up was 46 months (IQR 26, 75): no patients were lost to follow up. Estimated ± standard error five year survival was 61.5 ± 4.1%: elective 70.6 ± 4.7%, non-elective 43.2 ± 7.2%. CONCLUSION: TAR + FET achieved primary distal seal in 47% of patients, but late failure occurred in 21%. Distal repair was ultimately indicated in 84% of survivors without a primary distal seal and of these 70% underwent repair, almost 10% died before planned repair, and 13% were considered unfit. Earlier distal endovascular repair and better assessment of patient fitness may improve midterm outcomes.

Editor's Choice - Meta-Analysis of Compliance with Endovascular Aneurysm Repair Surveillance: The EVAR Surveillance Paradox.

OBJECTIVE: To compare the survival of patients who attended surveillance after endovascular aneurysm repair (EVAR) with those who were non-compliant. DATA SOURCES: MEDLINE and Embase were searched using the Ovid interface. REVIEW METHODS: A systematic review was conducted complying with the PRISMA guidelines. Eligible studies compared survival in EVAR surveillance compliant patients with non-compliant patients. Non-compliance was defined as failure to attend at least one post-EVAR follow up. The risk of bias was assessed with the Newcastle-Ottawa scale, and the certainty of evidence using the GRADE framework. Primary outcomes were survival and aneurysm related death. Effect measures were the hazard ratio (HR) or odds ratio (OR) and 95% confidence interval (CI) calculated using the inverse variance or Mantel-Haenszel statistical method and random effects models. RESULTS: Thirteen cohort studies with a total of 22 762 patients were included. Eight studies were deemed high risk of bias. The pooled proportion of patients who were non-compliant with EVAR surveillance was 43% (95% CI 36 - 51). No statistically significant difference was found in the hazard of all cause mortality (HR 1.04, 95% CI 0.61 - 1.77), aneurysm related mortality (HR 1.80, 95% CI 0.85-3.80), or secondary intervention (HR 0.66, 95% CI 0.31 - 1.41) between patients who had incomplete and complete follow up after EVAR. The odds of aneurysm rupture were lower in non-compliant patients (OR 0.63, 95% CI 0.39 - 1.01). The certainty of evidence was very low for all outcomes. Subgroup analysis for patients who had no surveillance vs. those with complete surveillance showed no significant difference in all cause mortality (HR 1.10, 95% CI 0.43 - 2.80). CONCLUSION: Patients who were non-compliant with EVAR surveillance had similar survival to those who were compliant. These findings question the value of intense surveillance in all patients post-EVAR and highlight the need for further research on individualised or risk adjusted surveillance.

Open Retroperitoneal Repair for Complex Abdominal Aortic Aneurysms.

BACKGROUND: Open surgical repair (OSR) of complex abdominal aortic aneurysms (CAAAs) can be challenging. We frequently utilize the retroperitoneal (RP) approach for such cases. We audited our outcomes with the aim of establishing the utility and safety of this approach. METHODS: Retrospective analysis was performed of all patients undergoing OSR of an unruptured CAAA via a RP approach in our center over a 7-year period. Data on repairs via a transperitoneal (TP) approach were collected to provide context. Demographic, operative, radiological, and biochemical data were collected. The primary outcome measure was 30-day/inpatient mortality. Secondary outcomes included the need for reoperation, incidence of postoperative chest infection, acute kidney injury (AKI) and length of stay (LOS). All patients received aortic clamping above at least one main renal artery. RESULTS: One hundred and three patients underwent OSR of an unruptured CAAA; 55 via a RP approach, 48 TP. The RP group demonstrated a more advanced pattern of disease with a larger median maximum diameter (65 vs. 61 mm, p= 0.013) and a more proximal extent. Consequently, the rate of supravisceral clamping was higher in RP repair (66 vs. 15%, p < 0.001). Despite this there were no differences in the observed early mortality (9.1 vs. 10%, NS); incidence of reoperation (10.9 vs. 12.5%, NS), chest infection (32.7 vs. 25%, NS), and AKI (52.7 vs. 45.8%, NS); or median LOS (10 vs. 12 days, NS) following RP and TP repair. CONCLUSION: OSR of CAAAs carries significant 30-day mortality. In patients unsuitable for fenestrated endovascular aortic repair or those desiring a durable long-term solution, OSR can be performed through the RP or TP approach. This study has demonstrated that in our unit RP repair facilitates treatment of more advanced AAA utilizing complex proximal clamp zones with similar perioperative morbidity and mortality compared with TP cases utilizing more distal clamping.

Evaluation of a hybrid pipeline for automated segmentation of solid lesions based on mathematical algorithms and deep learning.

We evaluate the accuracy of an original hybrid segmentation pipeline, combining variational and deep learning methods, in the segmentation of CT scans of stented aortic aneurysms, abdominal organs and brain lesions. The hybrid pipeline is trained on 50 aortic CT scans and tested on 10. Additionally, we trained and tested the hybrid pipeline on publicly available datasets of CT scans of abdominal organs and MR scans of brain tumours. We tested the accuracy of the hybrid pipeline against a gold standard (manual segmentation) and compared its performance to that of a standard automated segmentation method with commonly used metrics, including the DICE and JACCARD and volumetric similarity (VS) coefficients, and the Hausdorff Distance (HD). Results. The hybrid pipeline produced very accurate segmentations of the aorta, with mean DICE, JACCARD and VS coefficients of: 0.909, 0.837 and 0.972 in thrombus segmentation and 0.937, 0.884 and 0.970 for stent and lumen segmentation. It consistently outperformed the standard automated method. Similar results were observed when the hybrid pipeline was trained and tested on publicly available datasets, with mean DICE scores of: 0.832 on brain tumour segmentation, and 0.894/0.841/0.853/0.847/0.941 on left kidney/right kidney/spleen/aorta/liver organ segmentation.

Risk factors, risk stratification and risk-specific surveillance strategies after endovascular aneurysm repair: study protocol for a Delphi study by the International RIsk Stratification in EVAR (IRIS-EVAR) working group.

INTRODUCTION: Several risk factors for adverse events after endovascular aneurysm repair (EVAR) have been described, but there is no consensus on their comparative prognostic significance, use in risk stratification and application in determining postoperative surveillance. METHODS AND ANALYSIS: A scoping review of the literature was conducted to identify risk factors for adverse events after EVAR. Main adverse events were considered post-EVAR abdominal aortic aneurysm rupture and reintervention. Risk factors were grouped into four domains: (1) preoperative anatomy, (2) aortic device, (3) procedure performance and (4) postoperative surveillance. The Delphi methodology will be used to steer a group of experts in the field towards consensus organised into three tiers. In tier 1, participants will be asked to independently rate risk factors for adverse events after EVAR. In tier 2, the panel will be asked to independently rate a range of combinations of risk factors across the four domains derived from tier 1. A risk-stratification tool will then be built, which will include algorithms that map responses to signalling questions onto a proposed risk judgement for each domain. Domain-level judgements will in turn provide the basis for an overall risk judgement for the individual patient. In tier 3, risk factor-informed surveillance strategies will be developed. Each tier will typically include three rounds and rating will be conducted using a 4-point Likert scale, with an option for free-text responses. ETHICS AND DISSEMINATION: Research Ethics Committee and Health Research Authority approval has been waived, since this is a professional staff study and no duty of care lies with the National Health Service to any of the participants. The results will be presented at regional, national and international meetings and will be submitted for publication in peer-reviewed journals. The risk stratification tool and surveillance algorithms will be made publicly available for clinical use and validation.

Time-dependent mechanical behaviour of the aortic chronic dissection flap.

OBJECTIVES: The transition of aortic dissection from acute to chronic is poorly understood. We examined time-dependent mechanical behaviour and biochemical properties of chronic dissection tissues. METHODS: Aorta samples were obtained from 14 patients with mixed aetiology who were undergoing elective surgery for chronic dissected aneurysms, ranging from 3 months to 15 years post-dissection. The tissue elastic modulus and tissue deformation following application of loading for 5 h were measured for the false lumen (FL), true lumen (TL) and flap (FP) tissues with a custom-indentation technique. Collagen, elastin and glycosaminoglycan levels were determined with established biochemical assays. Elastin fragmentation was graded from histological sections. The number of tissues characterized was as follows: FP (n = 10), TL (n = 5 for biomechanical testing, n = 8 for biochemical analysis, n = 8 for histological assessment) and FL (n = 4). RESULTS: Tissues stiffness was highest in FP [59.8 (14.8) kPa] as compared with TL [50.7 (6.2) kPa] and FL [40.5 (4.7) kPa] (P = 0.023 and P = 0.006, respectively). FP [0.5 (0.08) mm] also exhibited reduced deformation relative to TL [0.7 (0.02) mm] and FL [0.9 (0.08) mm] (P = 0.003 and P = 0.006, respectively), lowest collagen concentration [FP: 40.1 (19.6) µg/mg, TL: 59.9 (19.5) µg/mg, P = 0.008; FL: 79.1 (32.0) µg/mg, P = 0.006] and the lowest collagen: elastin ratio [0.4 (0.1)] relative to the other tissues [TL; 0.6 (0.3), P = 0.006, FL; 1.5 (0.4); P = 0.003]. Significant elastin loss was evident in the FL-stained tissue sections whereas highly aligned, long fibres were visible in the FP and TL. A linear relationship was found between the stiffness, deformation and the time from the dissection event to surgical intervention for the FP. All data are presented as median (interquartile range). CONCLUSIONS: FP exhibited reduced time-dependent deformation and distinct biochemical properties relative to TL and FL irrespective of connective tissue disorder or the anatomical region of the dissection.

Onyx™ Cast Fragmentation After Embolization of Endoleaks.

PURPOSE: Endoleaks are common following endovascular aneurysm repair (EVAR), and the liquid embolic material Onyx has been widely used in their treatment. We report our experience of long-term morphological changes of Onyx casts on surveillance imaging. MATERIALS AND METHODS: We identified 10 patients over 10 years who underwent Onyx embolization in our institution. Morphological changes of Onyx casts were assessed on surveillance radiographs and computed tomography (CT) scans. Relevant outcome data and sequelae were obtained via electronic patient records. RESULTS: Twelve procedures were performed on 10 cases, 9 for type 2, and 1 for a type 1a endoleak. Five cases showed evidence of Onyx fragmentation on follow-up imaging ranging from a single fracture to gross fragmentation with migration of fragments. Of these 5, 3 had achieved primary success but 2 went on to develop recurrence of endoleak. Onyx volume ranged from 4 to 46.5 ml (median 10.5 ml) per patient with larger volumes demonstrating the most marked fragmentation on follow-up. Follow-up ranged from 9 months to 8 years (median 2.25 years). CONCLUSION: To our knowledge, this is the first report of Onyx fragmentation after endoleak embolization. If long-term morphological stability of the Onyx cast is necessary to maintain aneurysm seal, then Onyx may not offer a permanent solution to some patients with post-EVAR endoleaks. Our study cannot ascertain whether the observed changes were the cause or the effect of ongoing aneurysm growth, persistent endoleak, and/or other forces acting on the solidified polymer, but it raises important questions on the use of Onyx in this setting.

An International, Multicenter Retrospective Observational Study to Assess Technical Success and Clinical Outcomes of Patients Treated with an Endovascular Aneurysm Sealing Device for Type III Endoleak.

INTRODUCTION: Type III endoleaks post-endovascular aortic aneurysm repair (EVAR) warrant treatment because they increase pressure within the aneurysm sac leading to increased rupture risk. The treatment may be difficult with regular endovascular devices. Endovascular aneurysm sealing (EVAS) might provide a treatment option for type III endoleaks, especially if located near the flow divider. This study aims to analyze clinical outcomes of EVAS for type III endoleaks after EVAR. METHODS: This is an international, retrospective, observational cohort study including data from 8 European institutions. RESULTS: A total of 20 patients were identified of which 80% had a type IIIb endoleak and the remainder (20%) a type IIIa endoleak. The median time between EVAR and EVAS was 49.5 months (28.5-89). Mean AAA diameter prior to EVAS revision was 76.6±19.9 mm. Technical success was achieved in 95%, 1 patient had technical failure due to a postoperative myocardial infarction resulting in death. Mean follow-up was 22.8±15.2 months. During follow-up 1 patient had a type Ia endoleak, and 1 patient had a new type IIIa endoleak at an untreated location. There were 5 patients with aneurysm growth. Five patients underwent AAA-related reinterventions indications being: growth with type II endoleak (n=3), type Ia endoleak (n=1), and iliac aneurysm (n=1). At 1-year follow-up, the freedom from clinical failure was 77.5%, freedom from all-cause mortality 94.7%, freedom from aneurysm-related mortality 95%, and freedom from aneurysm-related reinterventions 93.8%. CONCLUSION: The EVAS relining can be safely performed to treat type III endoleaks with an acceptable technical success rate, a low 30-day mortality rate and no secondary ruptures at short-term follow-up. The relatively low clinical success rates, related to reinterventions and AAA enlargement, highlight the need for prolonged follow-up.

Effect of treatment of peripheral arterial disease on the onset of anaerobic exercise during cardiopulmonary exercise testing.

OBJECTIVE: Cardiopulmonary exercise testing (CPET) is often used to assess pre-operative fitness in elderly patients, in whom peripheral arterial disease (PAD) is highly prevalent, but may affect the results of CPET by early lactate release due to muscle ischemia. This study investigated the effect revascularization of PAD on oxygen delivery (VO2 ) during CPET. METHOD: We conducted a prospective cohort study of 30 patients, who underwent CPET before and after treatment of ilio-femoral PAD. The primary outcome measure was difference in VO2 at the lactate threshold (LT) before and after revascularization. Secondary outcome measures were the relationship between change in VO2 at LT and peak exercise and change in ankle-brachial index (ABI) differential. RESULTS: The study was approved by the North West-Lancaster Research and Ethics committee (reference 15/NW/0801) and registered in clinicaltrial.gov (reference NCT02657278). As specified in the study protocol, 30 patients were recruited but only 20 (15 men), with a mean age of 62 years, completed pre- and post-treatment CPETs. Twelve patients demonstrated an improvement in VO2 at LT after revascularization, but the difference did not achieve statistical significance (mean difference (95% CI) = 1.43 (-0.21 to 3.08) ml/kg/min; (p = 0.085). There was, however, a significant improvement in VO2 , VE/CO2 , workload and Borg breathlessness and leg fatigue score at peak exercise after revascularization. There was no significant correlation between change in VO2 at LT (r = -0.11, p = 0.65) or change in VO2 at peak and ABI differential (r = -0.14, p = 0.55). CONCLUSION: Revascularization of PAD led to significant improvement in multiple peak/maximal exercise parameters within a few weeks and without exercise training. We were unable to demonstrate a statistically significant improvement in VO2 at LT albeit in a majority of subjects this exceeded what we pre-defined as clinically significant.

COVID-19 and cardiac surgery: A perspective from United Kingdom.

The emergence of severe acute respiratory syndrome coronavirus 2 in December 2019, presumed from the city of Wuhan, Hubei province in China, and the subsequent declaration of the disease as a pandemic by the World Health Organization as coronavirus disease 2019 (COVID-19) in March 2020, had a significant impact on health care systems globally. Each country responded to this disease in different ways, however this was done broadly by fortifying and prioritizing health care provision as well as introducing social lockdown aiming to contain the infection and minimizing the risk of transmission. In the United Kingdom, a lockdown was introduced by the government on March 23, 2020 and all health care services were focussed to challenge the impact of COVID-19. To do so, the United Kingdom National Health Service had to undergo widespread service reconfigurations and the so-called "Nightingale Hospitals" were created de novo to bolster bed provision, and industries were asked to direct efforts to the production of ventilators. A government-led public health campaign was publicized under the slogan of: "Stay home, Protect the NHS (National Health Service), Save lives." The approach had a significant impact on the delivery of all surgical services but particularly cardiac surgery with its inherent critical care bed capacity. This paper describes the impact on provision for elective and emergency cardiac surgery in the United Kingdom, with a focus on aortovascular disease. We describe our aortovascular activity and outcomes during the period of UK lockdown and present a patient survey of attitudes to aortic surgery during COVID-19 pandemic.

Contemporary results of open thoracic and thoracoabdominal aortic surgery in a single United Kingdom center.

OBJECTIVE: To report our outcomes and identify predictors of mortality after open descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) repair in a specialist aortic center. METHODS: This retrospective observational cohort study included consecutive patients who underwent surgery at our institution between October 1998 and December 2019. The main outcome measures were mortality and major morbidities. A multivariate analysis was used to identify predictors of mortality. RESULTS: There were 430 patients who underwent DTA (n = 157) and TAA (n = 273) repair; 151 underwent surgery nonelectively. Forty-eight patients (11%) died within 30 days of surgery. The 30-day mortality was lower after elective surgery (3.1% after DTA repair and 9.9% after TAAA repair), whereas nonelective surgery had a 30-day mortality of 17.9%. Fourteen additional patients died in hospital after 30 days, one after nonelective DTA repair and 13 after TAAA repair (10 elective), all but one extent II. In-hospital mortality for the whole cohort improved over time, as the activity volume increased, except for patients undergoing extent II TAAA repair. Predictors of in-hospital mortality were age ≥70 years (odds ratio [OR], 3.36; 95% confidence interval [CI], 1.79-6.32; P < .001), extent II repair (OR, 4.39; 95% CI, 2.34-8.21; P < .001), nonelective surgery (OR, 2.72; 95% CI, 1.44, 5.12; P = .002), out-of-hours surgery (OR, 8.17; 95% CI, 2.16-30.95; P = .002), a left ventricular ejection fraction of <30% (OR, 9.86; 95% CI, 1.91-50.86; P < .006), and surgery for a degenerative aneurysm (OR, 2.20; 95% CI, 1.12-4.31; P = .02). The incidence of stroke and paraplegia was 7.1% and 0% after DTA repair and 9.9% and 3.3% after TAAA repair. Hemodialysis was necessary in 5.1% of cases after DTA repair and 22.7% after TAAA repair. CONCLUSIONS: Open thoracoabdominal aortic surgery carries significant risk to life, which is related to age, extent of aortic replacement, timing of surgery, and left ventricular function. Morbidity is considerable. Understanding these risks is fundamental for patient selection and the consent process of potential candidates for surgery, particularly in the elderly.