Early and late surgical outcomes of acute type A aortic dissection in patients aged 75 years and older

BACKGROUND: With the general increase in human lifespan, aortic surgeons are faced with an increasing prevalence of acute type A aortic dissection in the elderly. In this study, we reviewed early and late surgical outcomes of acute type A dissection (operation within 48 hours after onset) in patients aged 75 years and older. METHODS: Between 1990 and 1999, 109 patients underwent emergency operation for acute type A dissection at Omiya Medical Center. Twenty-three patients were aged 75 years and older (elderly group, mean age, 79.1 +/- 4.7 years) and 86 were younger than 75 years old (younger group, mean age, 58.7 +/- 10.8 years). Early and late outcomes of both groups were compared. RESULTS: The hospital mortality rates were 13.0% (3 of 23) in the elderly group and 10.5% (9 of 86) in the younger group (p = 0.71). In the elderly, actuarial survival rate (including the operative mortality rate) at 1, 3, and 5 years was 78% +/- 9% for each point. In the younger group, the rates were 88% +/- 4% at 1 year, 83% +/- 4% at 3 years, and 81% +/- 5% at 5 years (p = 0.57). Actuarial event-free rates were 84% +/- 8% at 1 year, 77% +/- 11% at 3 years, and 77% +/- 11% at 5 years in the elderly group. In the younger group, the rates were 96% +/- 2% at 1 year, 88% +/- 4% at 3 years, and 81% +/- 7% at 5 years (p = 0.27). CONCLUSIONS: No significant differences in the hospital mortality, actuarial survival, or event-free rates were observed between the two groups. Operation for type A acute aortic dissection in patients aged 75 years or older can be performed with acceptable risk of death, and long-term results are satisfactory.     

Survival and quality of life after repair of acute type A aortic dissection in patients aged 75 years and older justify intervention.

OBJECTIVE: Controversy still exists about averting expenditure of health care resources on the growing elderly population. This study evaluates clinical outcome of patients aged 75 years and older operated upon for acute type A aortic dissection. METHODS: Between January 1990 and April 2004, of 247 patients undergoing emergency operation for acute type A aortic dissection at our Institution, 40 patients (16%) were aged 75 years and older (mean 78+/-3 years, range 75-88 years) and represent the study population. On admission, 9 (22.5%) had cardiogenic shock/hypotension, 20 (50%) cardiac tamponade, 14 (35%) kidney failure, 11 (27.5%) limb ischemia, 3 (7.5%) neurologic deficit, and 1 (2.5%) myocardial ischemia. Surgical procedures included isolated replacement of the ascending aorta in 34 patients (85%), associated with total root replacement in 5 (12.5%), and with aortic valve replacement in 1 (2.5%). Eleven patients (27.5%) underwent aortic arch replacement (hemiarch: n=8, 20%; total arch: n=3, 7.5%). RESULTS: In-hospital mortality was 30% (12 patients). Mortality tended to be higher (8/21, 38% vs 4/19, 21%; p=NS) for patients presenting with any one of the following complications: tamponade, shock, brain and/or myocardial, renal, limb malperfusion. Actuarial survival at 1, 5, and 7 years was 93+/-5%, 80+/-8%, and 80+/-8%, respectively, and freedom from reoperation 97+/-2%, 97+/-2%, and 97+/-2%, respectively. Actuarial event-free rates were 94+/-3%, 90+/-5%, and 90+/-5%. Seventy-four percent of survivors are in NYHA FC I, and quality of life test (RAND SF-36) revealed a generalized perception of independency and well-being, comparable to an age-matched population. CONCLUSIONS: Overall results for emergency repair of acute type A aortic dissection in the elderly justify intervention, particularly in uncomplicated cases. Expeditious referral and intervention by lowering pre-operative dissection-related complications and comorbidities might help to improve results. Survivors show functional status and quality of life similar to contemporary individuals.     

Risk factors of mortality and permanent neurologic injury in patients undergoing ascending aortic and arch repair

OBJECTIVES: To analyze outcome in elderly patients after surgical repair of the ascending aorta and the aortic arch as compared with their younger counterparts and to determine risk factors of mortality and permanent neurologic injury.Patients and methods Between January 1995 and February 2003, a total of 369 patients underwent ascending aortic and arch repair. Indications for surgical intervention were acute type A dissections in 174 (47%) patients (<75 years, n = 147; > or =75 years, n = 27) and chronic atherosclerotic aneurysms in 195 (53%) patients (<75 years, n = 168; > or =75 years, n = 27). Emergency surgery was performed in 167 (45%) patients; 202 patients (54.7%) underwent surgery requiring deep hypothermic circulatory arrest. Pre- and intraoperative factors were evaluated by means of stepwise logistic regression analysis to determine risk factors of mortality and permanent neurologic injury. RESULTS: Overall in-hospital mortality was 11.6%. In-hospital mortality with regard to indication for surgical intervention was comparable in both age groups (type A dissection: <75 years, 15.6%; > or =75 years, 18.5%; P =.731; chronic atherosclerotic aneurysm: <75 years, 7.7%; > or =75 years, 7.4%; P =.933). Permanent neurologic injury was observed in 5.0%. Permanent neurologic injury with regard to surgical intervention was comparable in both age groups (type A dissection: <75 years, 8.8%; > or =75 years, 3.7%; P =.359; chronic atherosclerotic aneurysm: <75 years, 3.0%; > or =75 years, 3.7%; P =.843). Stepwise logistic regression analysis revealed preoperative hemodynamic instability (odds ratio 4.3; P =.000), duration of cardiopulmonary bypass (odds ratio 2.1; P =.001), and permanent neurologic injury (odds ratio 1.7; P =.033) but not age as independent predictors affecting mortality. Utilization of but not duration of deep hypothermic circulatory arrest was the only independent predictor of permanent neurologic injury (odds ratio 2.8; P =.019). CONCLUSIONS: Age shows a trend toward a higher risk of mortality but does not predict a higher incidence of permanent neurologic injury after ascending aortic and arch repair. As utilization of deep hypothermic circulatory arrest remains the only independent predictor of permanent neurologic injury, alternative approaches to maintain cerebral perfusion during ascending aortic and arch repair are warranted.     

Total and subtotal aortic replacement for extensive aortic dissection in patients with or without Marfan’s syndrome

OBJECTIVES: Extensive aortic dissection with multiple entries often found in Marfan's syndrome patients ultimately requires replacement of the whole aorta. We present a surgical strategy and results for total and subtotal aortic replacement. METHODS: Subjects were 18 patients, including 14 Marfan's patients undergoing total (n = 13) or subtotal (excluding aortic arch) aortic replacement (n = 5), for DeBakey type I aortic dissection (n = 13) and DeBakey type IIIb aortic dissection with annuloaortic ectasia (n = 5) between February 1991 and April 2001. Mean age was 39.9 +/- 0.8 years--34.9 +/- 6.6 years in Marfan's patients vs. 57.7 +/- 4.7 years in non-Marfan patients. All operations were staged, with the mean number required per patient 3.1 +/- 0.8. RESULTS: Early mortality was 0% and late mortality 11% (2 of 18). Paraplegia or paraparesis occurring in 11%. Except for these patients, all current survivors enjoy good quality of life. CONCLUSIONS: Total and subtotal aortic replacement for extensive aortic dissection may decrease mortality due to rupture or associated disease.     

Impact of an aggressive surgical approach on surgical outcome in type A aortic dissection

BACKGROUND: To evaluate the impact of an aggressive surgical approach on early and late outcome in type A aortic dissection. METHODS: From 1983 to 2001, 240 patients underwent operation for acute (n = 138) and chronic (n = 102) type A aortic dissection. The extent of distal aortic resection included the ascending aorta in 39 (16%) patients, hemiarch (HAR) in 47 (20%), and total arch (TAR) in 154 (64%), including 19 patients who also had their descending aorta replaced (DAR). RESULTS: The in-hospital mortality did not differ between TAR with or without DAR and other more conservative techniques (12.3% versus 16.3%). Actuarial survival at 10 years including in-hospital mortality was 72.4% +/- 3.3% and freedom from reoperation was 77.2% +/- 3.6% for all patients: neither was influenced by the extent of distal aortic resection or acuity of aortic dissection. Multivariate analysis revealed younger age and failure to resect the intimal tear to be independent determinants for late reoperation. However, in contrast to 22 patients who had more conservative operations, none of the patients with TAR required reoperation on the aortic arch through a sternotomy incision. CONCLUSIONS: An aggressive surgical approach did not adversely influence early and late survival following type A aortic dissection; it reduced the necessity of late reoperation and facilitated distal aortic reoperation.     

Is surgical intervention still indicated in recurrent aortic arch obstruction?

BACKGROUND: Introduction of balloon dilatation has become the standard treatment for recurrent aortic arch obstruction and has changed the therapeutic approach to patients with this disorder. OBJECTIVES: Whether all patients with recurrent aortic arch obstruction are candidates for balloon dilatation remains unanswered. In addition, only few reports have tried to compare the results between patients undergoing balloon dilatation or redo operations. METHODS: Since 1983, 97 patients underwent reintervention for recurrent aortic arch obstruction (42 dilations and 55 reoperations). Eight had immediate unsuccessful dilatation and were shifted to the surgical group (n = 63). The median age at reintervention was 21.7 months (10 days-45 years), and the median delay was 13.6 months (7 days-17 years). Anatomy of the aortic arch oriented the surgical approach to treat arch hypoplasia. It could be performed through a left thoracotomy in 52 patients, with extended end-to-end anastomosis in 34 patients, subclavian flap repair in 9 patients, conduit insertion in 6 patients, and patch enlargement in 3 patients. More recently, an anterior approach with cardiopulmonary bypass without circulatory arrest was applied to enlarge the patch in all the aortic arches. RESULTS: There was one early death in the surgical intervention group and 2 late deaths in the dilation group. Major complications and recurrence were higher in the dilated group (4 vs 0, P <.01, and 14 vs 5, P <.0004, respectively). At a mean follow-up of 11.8 +/- 4.1 years in the surgical intervention group and 7.5 +/- 2.5 years in the dilated group, systemic hypertension was normalized in all but 5 patients in the surgical intervention group and 6 patients in the dilated group. CONCLUSION: Reoperation for recurrent aortic arch obstruction can be performed safely, with low rates of mortality and morbidity. This approach should be considered versus balloon angioplasty, especially in patients older than 4 years and in the presence of aortic arch hypoplasia.     

Stentless full root bioprosthesis in surgery for complex aortic valve-ascending aortic disease: a single center experience of over 300 patients.

OBJECTIVE: The technically demanding full root aortic valve replacement necessitating coronary ostia reimplantation apparently leads to hesitation by some surgeons despite the superior hemodynamics and excellent long-term clinical performances of the stentless xenografts. Clinical data of stentless full root replacements was retrospectively analyzed in this perspective for validation. METHODS: From November 1999 to March 2007, 317 adult patients (male: 196, female, 121) underwent modified Bio-Bentall procedure using the Medtronic Freestyle xenograft as a full root replacement. Two hundred and three patients received an isolated root replacement or a root and ascending aortic replacement (ARR). In 114 patients a variety of concomitant procedures including coronary artery bypass grafting (n=32), mitral valve repair (n=11) and aortic arch replacement (n=36) were performed. (ARR+). RESULTS: Mean patient age was 70.3+/-10.2 years (range 17-94 years), 97 patients were 75 and older at time of procedure. Mean operative time for the ARR was 190+/-57 min with a clamp time of 88+/-27 min. Mean operative time for ARR+ group was 282+/-93 min with an average clamp time of 110+/-32 min. Overall operative mortality was 7.9% (25/317), for ARR it was 5.4% (11/203). Mean ICU stay was 4.9+/-8.1 days, mean hospital stay being 9.8+/-8.1 days. Necessity for bailout bypass surgery among patients with ARR was low at 1.5% (3/203) comparable to stented xenograft implantations. Echocardiography demonstrated excellent clinical results with low transvalvular gradients especially when a single suture inflow anastomosis technique was used. CONCLUSIONS: Full root stentless valve implantation preserving porcine root integrity is a valuable option in aortic valve/ascending aorta surgery. Though technically a more challenging operation, it does not lead to increased perioperative morbidity and mortality and can be beneficial mainly for elderly patients with small aortic roots with or without aortic root pathology.     

Fast track recovery of elderly coronary bypass surgery patients.

BACKGROUND: To ascertain whether early extubation and fast-track treatment protocols are feasible in elderly patients, we analyzed 487 consecutive patients who had isolated coronary artery bypass grafting between January 1995 and June 1997, constituting the experience of a single surgeon. METHODS: Management consistently applied to all patients emphasized early extubation protocol, tepid cardioplegia and normothermic bypass to reduce pump times, early mobilization and chest tube removal, and protocol treatment of atrial fibrillation. Elderly patients at least 70 years old (n = 176, mean age 75 years) were compared with younger patients (n = 311, mean age 58 years). RESULTS: The hospital mortality rate was 0.8% (4 of 487 patients), and there was no difference in the operative mortality rate of the older cohort versus the younger cohort (0.6% versus 0.9%; p > 0.05). Older patients had a higher incidence of peripheral vascular disease, congestive heart failure, prior strokes, renal failure, and cerebrovascular disease (p < 0.05). Early extubation was achieved in 71% of younger patients versus 57% of older cohort (95% confidence interval, 14%+/-9%; p = 0.002). Older patients had significantly higher incidence of postoperative atrial fibrillation (27% versus 14%; 95% CI, 13%+/-7%; p < 0.001), a factor responsible for shorter length of stay among younger patients (5.6+/-2.8 days versus 7.2+/-3.7 days; 95% CI, 1.6+/-0.3 days; p < 0.001). Nonetheless discharge before the fifth postoperative day was achieved in 34% of the elderly patients. CONCLUSIONS: Although elderly patients have a higher acuity of illness, critical pathways for accelerated discharge are safe and feasible in most elderly patients.     

Effects of bariatric surgery in older patients

OBJECTIVE: Evaluate the safety and efficacy of bariatric surgery in older patients. BACKGROUND: Because of an increased morbidity in older patients who may not be as active as younger individuals, there remain concerns that they may not tolerate the operation well or lose adequate amounts of weight. METHODS: The database of patients who had undergone bariatric surgery since 1980 and National Death Index were queried for patients <60 and >/= 60 years of age. GBP was the procedure of choice after 1985. Data evaluated at 1 and 5 years included weight lost, % weight lost (%WL), % excess weight loss (%EWL), % ideal body weight (%IBW), mortality, complications, and obesity comorbidity. RESULTS: Eighty patients underwent bariatric surgery: age 63 +/- 3 years, 78% women, 68 white, 132 +/- 22 kg, BMI 49 +/- 7 kg/m, 217 +/- 32%IBW. Preoperative comorbidity, was greater (P < 0.001) in patients >/= 60 years. There were no operative deaths but 11 late deaths. Complications: 4 major wound infections, 2 anastomotic leaks, 10 symptomatic marginal ulcers, 5 stomal stenoses, 3 bowel obstructions, 26 incisional hernias (nonlaparoscopic), and 1 pulmonary embolism. At 1 year after surgery (94% follow-up), patients lost 38 +/- 11 kg, 57%EWL, 30%WL, BMI 34.5 +/- 7 kg/m, %IBW 153 +/- 31. Comorbidities decreased (P < 0.001); however, %WL and %EWL and improvement in hypertension and orthopedic problems, although significant, were greater in younger patients. At 5 years after surgery (58% follow-up), they had lost 31 +/- 18 kg, 50%EWL, 26%WL, BMI 35 +/- 8 kg/m, and %IBW 156 +/- 36. CONCLUSIONS: Bariatric surgery was effective for older patients with a low morbidity and mortality. Older patients had more pre- and post-operative comorbidities and lost less weight than younger patients. However the weight loss and improvement in comorbidities in older patients were clinically significant.     

Elective Hypothermic Circulatory Arrest to Address Aortic Pathology Is Safe for the Elderly

Abstract   Background: Due to assumptions of excessive risk, hypothermic circulatory arrest (HCA) has been considered prohibitive in elderly patients. However, as more elderly patients are referred for assessment of difficult aortic valve, ascending aorta, and aortic arch pathology, the risk of HCA in these patients needs to be addressed. We hypothesized that the use of HCA would not increase mortality or complications in elderly patients compared to younger counterparts. Methods: We retrospectively reviewed the charts of adult patients who underwent elective HCA between January 1995 and June 2007. Of 147 procedures, 45 patients were ≥75 years old. These patients were compared to their younger counterparts in terms of comorbidities, operations, and complications. Results: Comparing patients ≥75 years old to their younger counterparts revealed no significant differences in outcomes including nearly identical rates of confusion (≥75 15% vs <75 9%, p > 0.5) and stroke (≥75 11% vs <75 7%, p > 0.2). There was also no difference in 30-day mortality (≥75 7% vs <75 7%, p = 0.9). Lengths of hospital stays and intensive care unit stays were longer in the older patients, but this was not statistically significant. Conclusion: In this study, elderly patients faired well with HCA compared to younger patients. These data suggest that the use of HCA is safe in selected elderly patients. Elderly patients should be considered for indicated procedures of the aortic valve, ascending aorta, and aortic arch regardless of age.     

Caudal anesthesia with lidocaine or bupivacaine: plasma local anesthetic concentration and extent of sensory spread in old and young patients

Continuous caudal peridural anesthesia with 2% lidocaine (6 mg/kg) or 0.75% bupivacaine (2.2 mg/kg), both with epinephrine 1:200,000, was studied in two groups of male patients, younger than 40 or older than 55 yr old, respectively. Patients receiving lidocaine in the younger group (n = 6) were 32 +/- 5.2 (mean +/- SD) yr old and weighed 75 +/- 12 kg, while those in the older group (n = 16) were 66 +/- 5.3 yr old and weighed 72 +/- 8.2 kg. Patients receiving bupivacaine in the respective groups were 27 +/- 7.0 yr old (n = 5), and 76 +/- 10 kg compared to 69 +/- 10 yr (n = 14) and 75 +/- 10 kg. Anesthesia was satisfactory in all patients. Extent of sensory anesthesia, peak plasma lidocaine or bupivacaine concentrations, and area under the plasma concentration-time curves were independent of age. No local anesthetic toxicity was observed and peak drug concentrations were below those commonly associated with toxicity.     

Treating renal cell cancer in the elderly

OBJECTIVE: To determine whether age and comorbidity are predictors of peri-operative complications and/or mortality in surgery for renal cell cancer in a retrospective study of patients aged >75 years. PATIENTS AND METHODS: Between 1993 and 2003, 1023 radical nephrectomies or nephron-sparing surgery for renal cell cancer were performed in 115 consecutive patients aged > or = 75 years and in 908 consecutive patients aged <75 years. The preoperative American Society of Anesthesiologists (ASA) score was used for risk stratification. Operative mortality and early complications (within 30 days of surgery) were reviewed. RESULTS: The younger patients had significantly lower ASA scores than the older patients. There were early complications in 31 of the 908 younger patients (3.4%) and in two of the 115 older patients (1.7%). Peri-operative mortality was higher in the older than in the younger patients (1.7% vs 0.3%; P = 0.29). Overall morbidity and mortality correlated with increasing ASA score but not with age (P < 0.05). CONCLUSIONS: Despite greater comorbidity in older patients, their morbidity and mortality did not differ significantly from that of younger patients. Advanced age alone should thus not be used as a criterion to deny surgery for renal cell carcinoma. However, older patients should be counselled regarding a tendency for increased comorbidity-related peri-operative mortality.     

Aortic dissection resulting from tear of transverse arch: is concomitant arch repair warranted?

Forty-seven patients with aortic dissection resulting from a primary tear located in the transverse aortic arch underwent surgical treatment. Twenty-six patients had acute type A, 7 had acute type B, 7 had chronic type A, and 7 had chronic type B aortic dissections. Of the 33 patients with acute dissections, 11 (7 acute type A and 4 acute type B) underwent concomitant arch repair with an operative (less than or equal to 30 days) mortality rate of 55% (35% to 73%, +/- 1 asymmetric 70% confidence limit) (2 of 7 acute type A and 4 of 4 acute type B). Concomitant arch repair was omitted in 22 patients with acute dissections (19 acute type A and 3 acute type B); the operative mortality rate was 41% (29% to 54%) (7 of 19 acute type A and 2 of 3 acute type B) (p = not significant versus arch repair). The overall survival rate for those with arch repair was 45% +/- 15% (+/- 1 standard error of the estimate) at 4 years, compared with 43% +/- 11% for patients without arch repair (p = not significant). Considering the type of dissection, the 4-year survival estimate for patients with acute type A dissections who underwent arch repair (5 hemiarch and 2 total arch) was 71% +/- 17% (versus 44% +/- 12% for acute type A patients without arch repair). There were no survivors among the 4 patients with acute type B dissections who had an arch repair (1 hemiarch and 3 total arch), whereas patients with acute type B dissections who did not undergo concomitant arch repair had a 4-year survival estimate of 33% +/- 27% (p = not significant versus arch repair). Four other patients with acute type B dissections resulting from an arch tear were managed medically and tended to have a slightly better prognosis (2-year survival estimate of 75% +/- 22% versus 14% +/- 13% for all surgically treated acute type B patients), but again this difference was not statistically significant. Multivariate analysis of the 47 surgical patients revealed that advanced age (p = 0.0008), preoperative dissection complications (p = 0.02), and other coexistent medical problems (p = 0.03) were the only significant, independent determinants of overall mortality. Initial arch repair was not a significant predictor. Nine percent (2/22) of patients with acute type A dissections who initially underwent isolated ascending aortic replacement required subsequent arch replacement; 1 died after reoperation.(ABSTRACT TRUNCATED AT 400 WORDS)     

Penetrating trauma in patients older than 55 years: a case-control study

BACKGROUND: Multiple studies have compared young and elderly blunt trauma patients, and concluded that, because elderly patients have outcomes similar to young patients, aggressive resuscitation should be offered regardless of age. Similar data on penetrating trauma patients are limited. STUDY DESIGN: In a retrospective review, 79 patients with penetrating injuries and age > or =55 were blindly matched for Injury Severity Score (ISS) and Abbreviated Injury Scores (AIS) with 79 penetrating trauma patients aged 15-35 years, who were admitted to the hospital over the same 4 year period (June 1994-June 1998). Mortality rates and length of stay in the intensive care unit (ICU) and the hospital were compared between the two groups. RESULTS: The average ISS for all patients was 12 (range 1-75) and identical for both groups. Both groups had similar injuries and were evaluated by an equal number and type of diagnostic studies. The mean ISS was not different between severely injured older and younger patients who required ICU admission or died. Among 32 nonsurvivors (18 older and 14 younger), older patients were more likely than younger patients to present with normal vital signs, although the comparison did not reach statistical significance (50% vs. 13%, P=0.25). There was a clinically significant trend for longer ICU (15+/-30 vs. 3+/-2 days, P=0.096) and hospital stay (10+/-18 vs. 6+/-8 days, P=0.08) among older patients, but mortality rates were similar (23% in older vs. 18% in younger, P=NS). Furthermore, these outcome parameters showed no difference when both groups were classified according to severity of injury or physiologic response. CONCLUSIONS: Following penetrating trauma, older patients arriving alive and admitted to the hospital are as likely to survive as younger patients who have injuries of similar severity, but at the expense of longer ICU and hospital stays.     

Video-assisted thoracoscopic division of vascular rings in pediatric patients

Vascular rings are usually repaired via left thoracotomy. We report our series of pediatric patients with vascular rings that were repaired thoracoscopically. From February 2002 to September 2004, 13 patients underwent video-assisted thoracoscopic surgical techniques (VATS) division of their vascular ring. Chest magnetic resonance arterography (MRA) and/or computed tomographic arteriography (CTA) were used to evaluate the vascular ring in most patients. Patients were chosen for VATS repair based on surgeon's choice and type of vascular ring. Data are expressed as mean +/- SD. The Children's Healthcare of Atlanta Institutional Review Board approved this retrospective chart review. Age and weight was 1.5 +/- 1.8 years (range: 4 months - 17 years) and 16.0 +/- 12.5 kg (range: 6.0 - 22.1 kg), respectively (n = 13). Associated diseases included congenital heart disease (n = 2). Symptoms included respiratory complaints (n = 6), dysphagia (n = 2), dysphagia and shortness of breath (n = 1), pneumonia (n = 2), tracheal deviation (n = 1), and one patient was asymptomatic. Vascular ring types included double aortic arch (n = 4) and right aortic arch with an aberrant left subclavian artery and a left ligamentum arteriosum (n = 9). Operating time was 70 +/- 20 minutes (range: 46 - 122 minutes). One patient had to be opened because of a large arch. Length of stay was 1.9 +/- 0.9 days (range: 1 - 3 days). There were no complications, and all patients improved clinically at follow-up. Thoracoscopic repair of certain types of vascular rings seems to be safe and effective in children. More patients, however, need to be studied.     

Early and long-term outcome in patients undergoing aortic root replacement with composite graft according to the Bentall's technique.

OBJECTIVE: The aims of this study were: (i) to evaluate the early and long-term outcome in patients undergoing aortic root replacement (ARR) with a composite graft; (ii) to identify the predictors for poor overall survival in this pool of patients. MATERIAL AND METHODS: Between January 1989 and December 2000, 212 patients underwent ARR with a CG. Mean age was 56+/-14 years, ranging from 16 to 77. Annuloaortic ectasia was the most frequent cause of aortic disease in this series, 81 (38%) patients, followed by atherosclerotic aneurysm 57 (27%) and type A acute aortic dissection 52 (24.5%). Marfan's syndrome was present in 37 (17.5%) patients. Duration of follow-up ranged from 1 to 120 months, mean 59+/-35 months. RESULTS: The overall hospital mortality was 16 (7.5%) patients. Eight of them had aortic dissection and four Marfan syndrome. The most frequently found complication resulted to be renal failure in 22 (10%) patients and low cardiac output in 15 (7%) patients. The incidence of perioperative myocardial infarction, neurological complications, respiratory complications, renal failure and coagulopathy incidence were significantly higher in patients with cardiopulmonary bypass (CPB) time >170 min, CA >40 min, and total aortic arch replacement. The actuarial survival at 1, 3 and 5 years resulted to be 91.8, 86 and 81.5%, instead the actuarial survival without re-operation resulted to be 89, 82 and 78%. The actuarial survival in patients with aortic dissection was significantly lower versus non-dissection (P=0.022). The multivariate analysis revealed the aortic dissection (P=0.03), age >65 years (P=0.014), associated coronary artery disease (P=0.002), NYHA functional class>/=3 (P=0.027), LVEF <35% (P=0.002) and total arch reconstruction (P=0.003) as strong predictors for poor overall survival in patients undergoing ARR. CONCLUSIONS: The ARR with a CG offers acceptable early and long-term outcome. The predictors for poor overall survival in patients undergoing ARR seems to be preoperative aortic dissection extended into the aortic arch, older age, depressed left ventricular function and associated coronary artery disease.     

The impact of patient age and aortic size on the results of aortobifemoral bypass grafting

OBJECTIVES: On the basis of the widespread belief that aortobifemoral bypass (ABF) represents the optimal mode of revascularization for patients with diffuse aortoiliac disease, vascular surgeons are often aggressive about its application in young adults. We undertook this retrospective evaluation of ABFs performed from 1980 to 1999 to determine whether the results justify this approach. Patients of less than 50 years of age (n = 45) were compared with those aged 50 to 59 years (n = 93) and those aged more than 60 years (n = 146). RESULTS: Younger patients were more likely to undergo operation for claudication than were older patients (72% versus 59% and 55%; P <.04). Younger patients were significantly more likely to be smokers (87%) but less likely to have diabetes, hypertension, or cerebrovascular disease. Bypasses were constructed in an end-to-end fashion in 71.1% of patients of less than 50 years versus 68.8% and 71.2% of older patients (P = not significant). The mean diameter of aortic grafts was significantly smaller in younger patients (14.6 mm) than in older patients (15.6 mm and 15.5 mm; P <.01). The need for a subsequent infrainguinal reconstruction was highest in the youngest patients (24% versus 17% and 7%; P <.01). Surgical mortality rates were low in all groups (0%, 1%, and 2.0% for increasing age groups; P = not significant). Five-year primary and secondary patency rates increased significantly with each increase in age interval: 5-year primary patency rate: less than 50 years, 66% +/- 8%; 50 to 59 years, 87% +/- 5%; more than 60 years, 96% +/-2% (P <.05 for all comparisons). Five-year secondary patency rates were: less than 50 years, 79% +/- 7%; 50 to 59 years, 91% +/- 4%; more than 60 years, 98% +/- 2% (P <.05 for all comparisons). Five-year survival rate was comparable in all three groups: less than 50 years, 93% +/- 5%; 50 to 59 years, 92% +/- 4%; more than 60 years, 87% +/- 4% (P = not significant). CONCLUSION: Increased virulence of aortic disease, smaller aortic size, and more progressive infrainguinal disease may all negatively impact the results of ABF in younger patients. Although 5-year results are acceptable, increased caution is warranted in the routine application of ABF in young patients without limb-threatening ischemia.     

Analysis of Anatomic Factors and Age in Patients Undergoing Carotid Angioplasty and Stenting

Recent data suggest that patient age >80 years may be associated with increased risk of periprocedural complications from carotid angioplasty and stenting (CAS). In this study, we analyzed anatomic risk factors in patients undergoing CAS based on age >80 or <80 years. Our hypothesis was that patients >80 would have more challenging anatomy. Between February 2003 and August 2004, 82 patients underwent CAS. Images for 57 lesions were available for review. Eighteen patients were ≥80 years old and 39 were <80. Cerebral protection devices, including EPI Filterwire, Percusurge, Accunet, and Angioguard, were used in all but two cases; and self-expanding stents (Wallstent, NexStent, Acculink, Precise) were placed in all. Arterial anatomic characteristics were assigned a score based on complexity and associated procedural risk. Characteristics evaluated using angiographic images were aortic arch elongation classification, arch calcification, common carotid/innominate stenosis, common carotid tortuosity, internal carotid tortuosity, index lesion length, index lesion calcification, and index lesion stenosis. Statistical analysis was performed using Fisher’s exact test. CAS was successfully completed in 98% of cases. The two patients in whom we could not perform CAS were 79 and 83 years old. The anatomic characteristics that were statistically significantly more complex/severe in patients ≥80 were arch calcification (p = 0.045), common carotid/innominate stenosis (p = 0.023), common carotid tortuosity (p = 0.049), and internal carotid tortuosity (p = 0.032). There was no statistically significant difference in arch elongation classification, lesion length, lesion calcification, or stenosis severity (p = nonsignificant). Overall, patients ≥80 years had an increased incidence of complex anatomic risk factors compared to younger patients (p < 0.001). Cerebrovascular accident without residual deficits occurred in two patients; both were >80 years old. Complex arterial anatomy is more often present in patients >80 years and may explain the increased complication rates associated with CAS. Pre- or intraoperative consideration of these characteristics may help provide better risk assessment in candidates for CAS. Presented at the Fifteenth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Steamboat Springs, CO, January 28-30, 2005.     

Emergency surgery results in life-threatening thoracic aortic disease

OBJECTIVE: Emergency surgery for thoracic aortic aneurysm continues to involve high mortality. We review our experience in emergency surgery for life-threatening thoracic aortic disease. METHODS: Between September 1994 and June 2000, 65 consecutive patients--38 men and 27 women aged 18 to 84 years (mean: 64.3 years)--underwent emergency surgery for thoracic aortic disease. Of these, 40 (61%) were treated for acute type A dissection, 16 (25%) for aortic rupture, and 9 (14%) for impending aneurysmal rupture. Ascending aorta repair was conducted in 21, aortic arch repair in 30, distal arch repair in 2, descending aorta repair in 9, and thoracoabdominal aorta repair in 3. Of the 65, 42 were under 70 years old and 23 were 70 years of age and older. RESULTS: Overall, 8 (12%) died in the hospital--3 (7.5%) of acute type A dissection, 3 (19%) of ruptured aneurysm, and 2 (22%) of impending rupture. Of these, 3 (7.1%) were younger than 70 years and 5 (22%) 70 years and older. The following perioperative factors significantly influenced hospital mortality: pump time (p = 0.019), postoperative severe cardiac failure (p = 0.006), postoperative respiratory failure (p = 0.045), and postoperative acute renal failure (p = 0.0007). Of the 57 survivors followed up for an average of 2.8 years (1 month to 6 years), 3-year survival was 73% overall--88% in patients younger than 70 years and 38% in those 70 years and older (p = 0.0004). Seven of the 9 patients suffering strokes during surgery died in the hospital (2) or after discharge (5). Overall hospital and late deaths involved 2 of 4 patients younger than 70 years and all of 5 patients 70 years and older. CONCLUSION: The majority of patients undergoing emergency surgery for life-threatening thoracic aortic disease can undergo graft replacement with acceptable mortality, morbidity, and late survival, but early and late mortality for patients older than 70 remains extremely high.     

Long-term results of heart transplantation in patients older than 60 years

BACKGROUND: Advanced age has been traditionally considered a relative contraindication for heart transplantation. Older patients are now considered as potential candidates for heart transplantation. The objective of this study was to evaluate the long-term results of heart transplantation in patients older than 60 years. METHODS: Between 1986 and 2001, 81 patients aged between 60 and 70 years (mean, 63 +/- 2 years) underwent heart transplantation. These patients were compared with 403 adult recipients younger than 60 years (mean, 47 +/- 11 years) who underwent transplantation during the same period. RESULTS: Thirty-day mortality was 6% (5/81) and 6% (25/403) in the older and younger patients, respectively (P = NS). Actuarial survival at 1, 5, and 10 years was 88% +/- 4% versus 83% +/- 2%, 75% +/- 5% versus 69% +/- 2%, and 50% +/- 9% versus 51% +/- 3% in the older and younger patients, respectively (P = NS). Older patients had significantly fewer rejection episodes (P =.003). Freedom from allograft coronary artery disease at 1, 5, and 10 years was 98% +/- 2% versus 92% +/- 2%, 85% +/- 6% versus 76% +/- 3%, and 81% +/- 7% versus 68% +/- 3% (P =.1). The incidences of infectious complication, cytomegalovirus infection, and posttransplant lymphoproliferative disorder were similar between the 2 groups, but older recipients were more likely to have a nonposttransplant lymphoproliferative disorder cancer (P =.002). Age at transplantation was not identified as an independent risk factor for early and late death. CONCLUSION: Heart transplantation in selected patients aged 60 years and older results in survival comparable with that of younger patients. Older patients have a lower risk of rejection but an increased risk of development of a nonposttransplant lymphoproliferative disorder cancer. Advanced age per se should not be considered as an exclusion criterion for transplantation.