Improvement in results of repair of type IV thoracoabdominal aortic aneurysms

Purpose: Although management of extensive type I and II thoracoabdominal aortic aneurysms (TAA) remains a formidable challenge, results of repair of TAA originating in the distal thoracic aorta (type IV) appear to have improved significantly. To quantitate this perceived improvement, the following retrospective study was undertaken to examine the results of type IV TAA repair at the Brigham & Women's Hospital over the past 18-year period.Methods: From July 1977 to September 1994, nonruptured atherosclerotic type IV TAAs were repaired in 58 patients. The mean age was 70 years, and associated risk factors included smoking (91%), hypertension (86%), coronary artery disease (52%), and previous aortic surgery (38%). Mean follow-up was 2.4 years (median 2 years).Results: Overall 30-day mortality was 5.3% (two deaths). Morbidity included stroke (3.5%), paraplegia (1.8%), permanent paraparesis (1.8%), myocardial infarction (7%), pneumonia (8.8%), gastrointestinal bleeding (11%), intestinal ischemia (5.3%), wound infection (7.0%), peripheral ischemia (5.3%), in-hospital dialysis (8.8%), and permanent dialysis (1.9%). Overall 5-year survival was 50%. With univariate analysis, survival was positively correlated with more recent year of operation (p = 0.002), smaller volume of intraoperative blood transfusion ( p = 0.02), decreased supraceliac ischemia time ( p = 0.04), and the use of the retroperitoneal approach ( p = 0.09). Multiple regression analysis revealed that the year of operation was the only independent predictor of survival ( p = 0.003). Subgroup analysis of patients who underwent operation between 1977 and 1987 (n = 13) and 1988 and 1994 (n = 45) revealed statistically significant improvements in length of hospital stay (46 + 12 vs 21 + 4 days, p = 0.02), postoperative dysrhythmia (50% vs 16%, p = 0.03), pstoperative maximum serum glutamic oxaloacetic-transaminase (516 + 234 vs 319 + 139 mg%, p = 0.04), incidence of hemorrhage requiring reexploration (33% vs 0%, p = 0.002), 30-day mortality (23% vs 0%, p = 0.009), and in-hospital mortality (39% vs 2.2%, p = 0.002).Conclusions: The modern mortality, morbidity, and survival of surgical repair of type IV TAA in our institution approaches that of infrarenal abdominal aortic aneurysm. (J Vasc Surg 1996;24:74-81.)