Independent associations with early mortality after open repair of Crawford extent IV thoracoabdominal aortic aneurysms.

OBJECTIVE: We aimed to identify outcomes and factors that independently associate with early mortality after open repair of Crawford extent IV thoracoabdominal aortic aneurysms, defined as aneurysms confined to the segment below the diaphragm. METHODS: This retrospective analysis included 721 extent IV thoracoabdominal aortic aneurysm repairs performed in our institution from 1986 to 2021. Indications for repair were aneurysm without dissection in 627 cases (87.0%) and aortic dissection in 94 cases (13.0%). Overall, 466 patients (64.6%) were symptomatic preoperatively; 124 (17.2%) procedures were performed in patients with acute presentation, including 58 (8.0%) ruptured aneurysms. RESULTS: Operative death occurred after 49 (6.8%) repairs. Persistent renal failure necessitating dialysis occurred after 43 (6.0%) repairs. Binary logistic regression modeling revealed that previous extent II thoracoabdominal aortic aneurysm repair, chronic kidney disease, previous myocardial infarction, urgent or emergency repair, and longer crossclamp times during surgery were independently associated with operative mortality. Among early survivors (n = 672), competing risk analysis revealed that cumulative incidence of mortality and reintervention rates at 10 years were 74.8% (95% confidence interval, 71.4%-78.5%) and 3.3% (95% confidence interval, 2.2%-5.1%), respectively. CONCLUSIONS: Although patient comorbidities contributed to operative mortality, factors associated with the repair, such as urgent or emergency status, the duration of aortic crossclamping, and certain types of complex reoperation, also played prominent roles. Patients who survive the operation can expect a durable repair that usually is free from late reintervention. Expanding our collective knowledge regarding patients who undergo open repair of extent IV thoracoabdominal aortic aneurysms will enable clinicians to establish best practices and improve patient outcomes.

Thoracoabdominal aortic aneurysm in women: many questions remain regarding their poor outcome.

Thoracoabdominal aortic aneurysms (TAAAs) affect approximately 5.9/100,000 persons per year, with a male:female ratio of approximately 1.5-1.7:1. Data exploring sex-related variations in epidemiology and clinical presentation are scarce, as women are normally under-represented in clinical trials. As female hormones and their receptors greatly impact the functions of the vascular cells and aneurysm etiology and extent, the age at surgery and comorbidities also differ between men and women. Additionally, female patients have smaller anatomic structures, including visceral/infrarenal aorta and iliac arteries, than most men. Thus, aneurysms of a certain diameter can represent more advanced disease in women comparatively, than the same-sized aneurysms in males, and be the cause of delayed and often emergent treatment. Adjusting the aortic diameter threshold is recommended for surgery using aortic size index (ASI) [aortic diameter in cm/body surface area (BSA) in m2] or aortic height index (AHI) (aortic diameter in cm/patient height in m) indices in patients who are significantly shorter or taller than average, but no specific sex-related size criteria have been indicated so far for TAAA. Data about TAAA outcomes are conflicting, but female sex has been demonstrated to be an independent risk factor for increased major postoperative complications (i.e., bleeding, acute limb ischemia, renal failure, bowel ischemia, spinal cord ischemia) with longer hospital and intensive unit care stay and in-hospital and 30-day mortality following endovascular treatment and increased long-term mortality following open repair. Despite this evidence, sex does not influence TAAA management strategies and currently the allocation to open or endovascular repair is based on anatomy and clinical setting. In light of these disadvantaged outcomes, further efforts are needed to better understand the sex-related differences in the TAAA diagnosis and management in order to allow prompt and appropriate treatment of female patients.

Contemporary Surgical Strategies for Acute Type A Aortic Dissection.

Surgical techniques and organ protection strategies for acute type A aortic dissection (ATAAD) have evolved considerably over the years. Nonetheless, open surgical repair remains a complex procedure, and there is a lack of consensus regarding many aspects of repair. In patients with dissection limited to the ascending aorta (DeBakey type II), repair typically involves replacement of only the affected segment, barring substantial aortic dilation to address elsewhere. In contrast, most patients with ATAAD have dissection extending into the thoracoabdominal aorta (DeBakey type I); in these cases, consideration must be given as to how much of the aortic arch and distal aorta to incorporate into the index repair, and several open and hybrid options exist. Herein, we review contemporary surgical strategies for ATAAD and clarify specific areas of controversy, in an effort to elucidate the optimal operative approach. In general, a limited index repair aimed at ensuring operative survival is typically the best option, whereas extended repair should be reserved for carefully selected patients who are most likely to benefit.

Spinal cord deficit after 1114 extent II open thoracoabdominal aortic aneurysm repairs.

OBJECTIVE: Crawford extent II repairs are the most extensive thoracoabdominal aortic aneurysm operations and pose the greatest risk of postoperative spinal cord deficit. We sought to examine spinal cord deficit after open extent II thoracoabdominal aortic aneurysm repair to identify predictors of the most serious type: persistent paraplegia or paraparesis. METHODS: We included 1114 extent II thoracoabdominal aortic aneurysm repairs performed from 1991 to 2017. Intercostal/lumbar artery reattachment (n = 959, 86.1%) and cerebrospinal fluid drainage (n = 698, 62.7%) were used to mitigate the risk of postoperative spinal cord deficit. We used univariate and multivariable analyses to examine spinal cord deficit and identify predictors of persistent paraplegia or paraparesis, defined as paraplegia or paraparesis present at the time of early death or hospital discharge. RESULTS: Spinal cord deficit developed after 151 (13.6%) repairs: 86 (7.7%) cases of persistent paraplegia or paraparesis (51 paraplegia; 35 paraparesis) and 65 (6.1%) cases of transient paraplegia or paraparesis. Patients with spinal cord deficit were older (median 68 vs 65 years, P < .001) and had more rupture (6.6% vs 2.2%, P = .002) and urgent/emergency repair (25.2% vs 16.9%, P = .01) than those without. Persistent paraplegia or paraparesis developed immediately in 47 patients (4.2%) and was delayed in 39 patients (3.5%). Urgent/emergency repair (relative risk ratio, 2.31; P = .002), coronary artery disease (relative risk ratio, 1.80, P = .01), and chronic symptoms (relative risk ratio, 1.76, P = .02) independently predicted persistent paraplegia or paraparesis. Reattaching intercostal/lumbar arteries (relative risk ratio, 0.38, P < .001) and heritable disease (relative risk ratio, 0.36, P = .01) were protective. Early and late survival were poorer in those with persistent paraplegia or paraparesis than in those without. CONCLUSIONS: Spinal cord deficit after extent II thoracoabdominal aortic aneurysm repairs remains concerning; survival is worse in patients with persistent paraplegia or paraparesis. The complexity of spinal cord deficit and persistent paraplegia or paraparesis warrant further study.

Reoperative surgery on the thoracoabdominal aorta.

OBJECTIVE: Since the advent of endovascular repair for aortic aneurysms, many centers have justified the use of endovascular approaches in patients with previous open distal aortic repair by deeming these patients "high risk" because of their previous operation. We sought to determine whether patients who undergo reoperative repair for thoracoabdominal aortic aneurysm (TAAA) have worse outcomes than patients who undergo non-reoperative repair. METHODS: We reviewed our data on 3379 TAAA repairs from 1986 to 2016. We compared patients' preoperative characteristics, surgical variables, and outcomes among reoperative (n = 726) and non-reoperative (n = 2653) cases. Furthermore, we examined reoperative indications to identify repairs performed because of repair failure (n = 93) and reoperations performed as an adjacent extension of repair (n = 633). A multivariable analysis was conducted to identify predictors of adverse events by using relevant preoperative and intraoperative factors. RESULTS: The operative mortality rate did not significantly differ between groups (8.1% for reoperative vs 7.3% for non-reoperative; P = .5); in addition, reoperative repair was not associated with an increased risk of adverse event. However, Kaplan-Meier survival analysis showed that over the first 10 years, the reoperative groups fared significantly worse than the non-reoperative group (P < .001) (survival estimates at 10 years: 23.9% ± 4.9% for patients with repair failure, 28.4% ± 2.0% for those with extension of repair, and 40.1% ± 1.1% for non-reoperative repairs). CONCLUSIONS: We were unable to detect noteworthy differences in early outcomes between reoperative and non-reoperative TAAA repair. However, mid-term results indicate worse survival for patients who undergo reoperative surgery.

The impact of preoperative chronic kidney disease on outcomes after Crawford extent II thoracoabdominal aortic aneurysm repairs.

OBJECTIVE: To determine whether preoperative chronic kidney disease (CKD) is predictive of poor outcomes in patients who undergo Crawford extent II thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: Data were collected from patients with CKD (defined as a preoperative estimated glomerular filtration rate <60 mL/min/1.73 m2; n = 399) and without CKD (n = 604) who underwent extent II TAAA repair during 1991 to 2016. We used univariate, multivariable, and propensity score matching analyses to compare outcomes between these 2 groups. RESULTS: Compared with patients without CKD, patients who presented with CKD were older and had greater rates of comorbidities, including coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Patients with CKD had higher rates of operative mortality and adverse events. After propensity analysis, patients with CKD had greater rates of adverse event and renal failure necessitating dialysis, but had comparable rates of operative death to patients without CKD. Multivariable modeling indicated that CKD independently predicted adverse event (relative risk ratio [RRR] = 1.61; P = .01) and renal failure (RRR = 1.86; P = .02) after repair. After adjustment for median age, patients with CKD had substantially worse mid-term survival than those without (23.9 ± 2.4% vs 48.5 ± 2.5% at 10 years; P < .001). CONCLUSIONS: In patients who present with CKD, extent II open TAAA repair carries considerable risks of operative death and adverse events. Further investigation is needed to improve renal protection during such repair.

Are outcomes of thoracoabdominal aortic aneurysm repair different in men versus women? A propensity-matched comparison.

OBJECTIVE: Women fare worse than men after many cardiovascular operations, including coronary artery bypass grafting and valve surgery. We sought to determine whether sex affects outcomes after open thoracoabdominal aortic aneurysm repair. METHODS: We evaluated data on 3353 consecutive patients (1281 women, 38.2%) who underwent open thoracoabdominal aortic aneurysm repair between October 1986 and July 2015. We compared preoperative characteristics, surgical variables, and outcomes between men and women in the overall group. A propensity-matching analysis was performed to adjust for preoperative and intraoperative differences. A multivariable analysis was conducted to identify predictors of poor outcomes using relevant preoperative and intraoperative factors. RESULTS: Men had a significantly higher prevalence of comorbid conditions, including coronary artery disease, and presented more often with dissection; women were slightly older than men (median age, 69 [62-74] years vs 67 [57-73] years; P < .001) and more often symptomatic. Men underwent extent II and IV repairs more often, whereas women more often had extent I and III repairs. The propensity analysis resulted in 958 matched pairs. Overall, women and men had similar early mortality (7.9% vs 7.2%, P = .5) and adverse event rates (14.8% vs 14.1%, P = .6), which were similar in propensity-matched groups. Multivariable analysis showed that predictors of operative death and adverse event differed between the sexes. Survival and freedom from repair failure were similar between the overall and matched groups. CONCLUSIONS: Men and women who undergo thoracoabdominal aortic aneurysm repair have similar outcomes, but there are important differences in several perioperative factors and predictors of poor outcomes.

Prognostic significance of early aortic remodeling in acute uncomplicated type B aortic dissection and intramural hematoma.

BACKGROUND: Patients with Stanford type B aortic dissections (ADs) are at risk of long-term disease progression and late complications. The aim of this study was to evaluate the natural course and evolution of acute type B AD and intramural hematomas (IMHs) in patients who presented without complications during their initial hospital admission and who were treated with optimal medical management (MM). METHODS: Databases from 2 aortic centers in Europe and the United States were used to identify 136 patients with acute type B AD (n = 92) and acute type B IMH (n = 44) who presented without complications during their index admission and were treated with MM. Computed tomography angiography scans were available at onset (≤14 days) and during follow-up for those patients. Relevant data, including evidence of adverse events during follow-up (AE; defined according to current guidelines), were retrieved from medical records and by reviewing computed tomography scan images. Aortic diameters were measured with dedicated 3-dimensional software. RESULTS: The 1-, 2-, and 5-year event-free survival rates of patients with type B AD were 84.3% (95% confidence interval [CI], 74.4-90.6), 75.4% (95% CI, 64.0-83.7), and 62.6% (95% CI, 68.9-73.6), respectively. Corresponding estimates for IMH were 76.5% (95% CI, 57.8-87.8), 76.5% (95% CI, 57.8-87.8), and 68.9% (95% CI, 45.2-83.9), respectively. In patients with type B AD, risk of an AE increased with aortic growth within the first 6 months after onset. A diameter increase of 5 mm in the first half year was associated with a relative risk for AE of 2.29 (95% CI, 1.70-3.09) compared with the median 6 months' growth of 2.4 mm. In approximately 60% of patients with IMH, the abnormality resolved within 12 months and in the patients with nonresolving IMH, risk of an adverse event was greatest in the first year after onset and remained stable thereafter. CONCLUSIONS: More than one third of patients with initially uncomplicated type B AD suffer an AE under MM within 5 years of initial diagnosis. In patients with nonresolving IMH, most adverse events are observed in the first year after onset. In patients with type B AD an early aortic growth is associated with a greater risk of AE.

Outcomes of 3309 thoracoabdominal aortic aneurysm repairs.

OBJECTIVE: Since the pioneering era of E. Stanley Crawford, our multimodal strategy for thoracoabdominal aortic aneurysm repair has evolved. We describe our approximately 3-decade single-practice experience regarding 3309 thoracoabdominal aortic aneurysm repairs and identify predictors of early death and other adverse postoperative outcomes. METHODS: We analyzed retrospective (1986-2006) and prospective data (2006-2014) obtained from patients (2043 male; median age, 67 [59-73] years) who underwent 914 Crawford extent I, 1066 extent II, 660 extent III, and 669 extent IV thoracoabdominal aortic aneurysm repairs, of which 723 (21.8%) were urgent or emergency. Repairs were performed to treat degenerative aneurysm (64.2%) or aortic dissection (35.8%). The outcomes examined included operative death (ie, 30-day or in-hospital death) and permanent stroke, paraplegia, paraparesis, and renal failure necessitating dialysis, as well as adverse event, a composite of these outcomes. RESULTS: There were 249 operative deaths (7.5%). Permanent paraplegia and paraparesis occurred after 97 (2.9%) and 81 (2.4%) repairs, respectively. Of 189 patients (5.7%) with permanent renal failure, 107 died in the hospital. Permanent stroke was relatively uncommon (n = 74; 2.2%). The rate of the composite adverse event (n = 478; 14.4%) was highest after extent II repair (n = 203; 19.0%) and lowest after extent IV repair (n = 67; 10.2%; P < .0001). Estimated postoperative survival was 83.5% ± 0.7% at 1 year, 63.6% ± 0.9% at 5 years, 36.8% ± 1.0% at 10 years, and 18.3% ± 0.9% at 15 years. CONCLUSIONS: Repairing thoracoabdominal aortic aneurysms poses substantial risks, particularly when the entire thoracoabdominal aorta (extent II) is replaced. Nonetheless, our data suggest that thoracoabdominal aortic aneurysm repair, when performed at an experienced center, can produce respectable outcomes.