Operative outcomes after open repair of descending thoracic aortic aneurysms in the era of endovascular surgery.

BACKGROUND: Since the advent of endovascular techniques for repair of descending thoracic aortic aneurysms (DTAAs), there has been a relative paucity of current data for open repairs. The purpose of this study was to assess the operative and long-term outcomes in a contemporary series of open repairs of DTAAs. METHODS: We conducted a retrospective review of 68 patients (63±14.5 years) who underwent DTAA repairs between January 1999 and December 2010. Forty-two patients (62%) were male, 16 (24%) had chronic obstructive pulmonary disease, 7 (10%) required dialysis preoperatively, 11 (16%) had contained rupture, 25 (37%) had previous cardioaortic operations, and 10 (15%) had previous aortic arch replacement (stage 1 elephant trunk). The entire descending thoracic aorta was replaced in 34 patients (50%). Cardiopulmonary bypass was used in 64 patients (94%) and deep hypothermic arrest in 22 (32%). RESULTS: In-hospital mortality was 3% (2 patients). There was no immediate paraplegia. Delayed paraplegia developed in 1 patient (1.5%). Postoperative stroke occurred in 3 patients (4.4%), and 20 (29%) required prolonged ventilatory support (intubation≥48 hours). New-onset renal insufficiency (creatinine≥2.5 mg/dL) developed postoperatively in 6 patients (9%), and 1 (1.5%) required temporary dialysis. The median follow-up time was 5.8±3.8 years. Sixteen of the 66 operative survivors (24.2%) died during follow-up. Probability of survival was 82%±0.05% at 5 years and 67%±0.07% at 10 years. Reintervention was necessary in 4 patients (6%). Freedom from reintervention was 98%±0.02% at 5 years and 89%±0.06% at 10 years. The univariable predictor of long-term death was postoperative reintubation (p<0.05). CONCLUSIONS: In the era of endovascular repair of DTAAs, operative death and morbidity outcomes for open repairs are observed to be low. In addition to good long-term survival rates, open repairs are durable, as evidenced by low reintervention rates.

Outcomes of open surgical repair for chronic type B aortic dissections.

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

Somatosensory-evoked potential-guided intercostal artery reimplantation in thoracoabdominal aortic aneurysm surgery.

OBJECTIVE: This study was undertaken to evaluate the use of somatosensory-evokedpotential (SSEP) monitoring on intercostal artery reimplantation (IAR) and spinal cord ischemia rates during thoracoabdominal ortic aneurysm repair. METHODS: Fifty-two patients had thoracoabdominal aortic aneurysm repair with IAR under SSEP guidance and 79 patients had repair with routine IAR without SSEP guidance from 1999 to 2010. RESULTS: No differences were observed between the two groups in age (63.1 ± 11.6 vs 64.8 ± 9.8 years), sex (57.7% vs 50.6% men), chronic dissections (40.4% vs 44.3%), renal insufficiency (11.5% vs 10.1%), and Crawford type 1 and 2 aneurysms (53.9% vs 53.9%). There was one case (1.9%) of immediate paraplegia and one case (1.9%) of delayed paraplegia in the SSEP group versus 2 cases (2.5%) of immediate paraplegia in the non-SSEP group (P = 0.92). In the SSEP group, 38 patients (73.1%) had SSEP changes, but only 15 (28.8%) required reimplantation. There were fewer IARs in the SSEP group compared with the non-SSEP group (28.8% vs. 59.5%, P = 0.004). No difference was observed in 30-day mortality between the SSEP and the non-SSEP group (3.9% vs. 7.6%, P = 0.48). CONCLUSIONS: The use of SSEP monitoring led to a significant decrease in the need for IAR without increasing the paraplegia rate.