Thoracoabdominal Aortic Aneurysm Repair: Results of Conventional Open Surgery

ObjectivesThe aim of this study is to report our experience in the surgical repair of thoracoabdominal aortic aneurysms (TAAAs) over the last 27 years against the background of evolving surgical techniques.MethodsWe reviewed the prospectively collected data of 571 patients who underwent open TAAA repair between 1981 and 2008. Data were analysed using univariate and multivariate analysis (logistic regression). Pre-, intra- and postoperative risk factors were used to develop risk models for in-hospital mortality, spinal cord deficit and renal failure. Recent published series were used to highlight the different treatment modalities and explore results.ResultsSeventy patients (12.3%) died in the hospital, the 30-day mortality was 8.9%, 37 patients (6.5%) required postoperative dialysis and 47 patients (8.3%) developed paraplegia or paraparesis. The incidence of paraplegia in the left heart bypass group was 4.4%. The predictors for hospital mortality were increasing age (odds ratio 1.096 per year, 95% confidence interval (CI): 1.05–1.14) and the need for haemodialysis (odds ratio 10, 95% CI: 4.7–21.1). For postoperative spinal cord deficit, we found three protecting factors: age above 75 years (odds ratio 0.14, 95% CI: 0.19–1.09), the presence of a post-dissection aneurysm (odds ratio 0.4, 95% CI: 0.17–0.94) and the combined use of cerebrospinal fluid drainage and motor-evoked potentials (odds ratio 0.28, 95% CI: 0.14–0.56). The urgency of procedure (odds ratio 4, 95% CI: 1.8–9) and preoperative serum creatinine level (odds ratio 1.007 per micromole per litre, 95% CI: 1.0–1.01) were significant risk factors for renal failure.ConclusionsOpen TAAA repair intrinsically has substantial complications, of which spinal cord ischaemia and renal failure are the most devastating, despite major progress in our understanding of the pathophysiology and operative strategy. An overview of the results of recently published series is given along with an analysis of our data.     

Hospital Readmissions Following Abdominal Aortic Aneurysm Repair

In-hospital outcomes associated with abdominal aortic aneurysm (AAA) repair are well described. However, little is known about post-discharge readmission rates, lengths of stay, associated mortality, and costs. We examined 206 consecutive patients who underwent AAA repair at two American hospitals between 1998 and 2000. Index hospitalization and 6-month readmission data were extracted from a resource and cost accounting system used by both hospitals. Among the 206 patients, 183 survived until discharge (mortality rate 11.2%). Among the surviving patients, 38 (21.0%) were readmitted within 6 months. Half of the readmissions occurred within two weeks of discharge, with patients presenting with a diverse array of complications. Nonelective repair and diabetes mellitus were independent predictors of hospital readmission (OR=2.83, 95% CI=1.25-6.40, p=0.01; OR=6.60, 95% CI=1.02-42.4, p=0.047, respectively). For each readmission, the mean length of stay was 10.7±2.5 days and the mean cost was $13,397±3,381. The cumulative number of hospital days during the 6 months post-discharge was 17.7±3.5 days for each readmitted patient and the mean per-patient total cost was $23,262±5,478. The mortality rate among readmitted patients was 13.2%. Overall, readmissions following AAA repair accounted for a cost >50% over and above the cost of the readmitted patients index hospitalization. Hospital readmissions are common during the 6 months following AAA repair. Patients who are readmitted experience long lengths of stay and high mortality rates, and their care incurs high costs.Dr. Eisenberg is a Physician-Scientist of the Quebec Foundation for Health Research. Dr. Pilote is a Physician-Scientist of the Canadian Institutes for Health Research.     

Thoracoabdominal Aortic Aneurysm Repair in Cardiac Transplant Recipients

We present here two cases of asymptomatic thoracoabdominal aortic aneurysms that were successfully operated on in heart transplant patients 8 and 23 months after transplantation. Thoracoabdominal aortic aneurysm was present prior to transplantation in one patient. In the other patient only the abdominal aortic aneurysm was found before transplantation. Indications for transplantation were ischemic and valvular cardiomyopathy. Surgical aortic aneurysm repair was performed with the standard technique. Both patients were discharged from the hospital. The possible contributing factors to the development and enlargement of aortic aneurysms and perioperative assessment are also discussed. Radiologic surveillance is warranted in any heart transplant recipient with abdominal or thoracoabdominal aortic aneurysms because of the more rapid aneurysm expansion.     

Prevention of Paraplegia during Thoracoabdominal Aortic Aneurysm Repair

Paraplegia affects up to 22% of patients undergoing thoarcoabdominal aneurysm surgery, producing long-term morbidity and a significant burden to healthcare. This article discusses the mechanisms that may lead to paraplegia during open and endovascular repair from an anatomical and physiological perspective. There are many adjuncts that must be considered to reduce the risk of spinal cord injury, such as revascularisation of intercostal arteries, maintenance of high mean blood pressure, spinal cord drainage and cooling. These adjuncts are discussed, highlighting the evidence available for each method and the practical ways in which they may be used.     

Erectile Function After Open or Endovascular Abdominal Aortic Aneurysm Repair

Open abdominal aortic aneurysm repair has been reported to be associated with impairment of sexual function in men, most likely because of autonomic nerve injury and pelvic blood flow changes. Endovascular aneurysm repair does not involve dissection in the area of the iliac bifurcation and therefore may be associated with lower incidence of sexual dysfunction as compared to open repair. We conducted a retrospective study of males after open and endovascular abdominal aortic aneurysm repair to determine if there is a significant difference in the incidence of sexual dysfunction between the two procedures. A modified International Index of Erectile Function Questionnaire was used to access sexual function before and after aneurysm repair. The questionnaire was mailed to all male patients who underwent abdominal aortic aneurysm repair from January 1, 1999 to July 15, 2002. The questionnaire asked patients questions regarding their sexual function before and 3 months after the repair. Questionnaire scores for domains of sexual function (erectile function, orgasmic function, intercourse satisfaction, and overall satisfaction) as well as the total questionnaire score were analyzed. The chi-square and Wilcoxons signed ranks test were used for statistical comparisons, with p < 0.05 considered significant. Logistic regression was used to examine association. Two hundred ninety-three questionnaires were mailed and 90 were returned completed. There was no difference for the total questionnaire score or the erectile function score before the procedure. Based on the questionnaire score, erectile function worsened after open AAA repair (p = 0.002). Orgasmic function also deteriorated after open AAA repair (p = 0.001). Endovascular repair was not accompanied by decreased erectile or orgasmic function (p = 0.057 and p = 0.068, respectively). Impairment of erectile function was not associated with age, diabetes, or the number of patent hypogastric arteries after aneurysm repair, but there was a significant association between impaired erectile function and open aneurysm repair (p = 0.036). Endovascular repair of abdominal aortic aneurysms is associated with significantly less impairment of erectile and orgasmic function than that with open repair. Preservation of sexual function after endovascular as compared to open repair should be among the factors considered when weighing treatment options for an abdominal aortic aneurysm in a sexually active male.     

Long-Term Outcomes After Open Repair for Ruptured Abdominal Aortic Aneurysm

World Journal of Surgery - Early mortality in ruptured abdominal aneurysm (rAAA) is high, but data on long-term outcome are scarce. The aim of this study was to investigate the long-term outcome in...     

Thoracoabdominal Aortic Aneurysm Repair in Patients with Single Kidney

p < 0.05. However, there was a significantly higher incidence of hypertension (97% versus 78%), coronary artery disease (50% versus 34%), and renal artery stenosis ipsilateral to functioning kidneys (88% versus 26%) in the single-kidney group than in the reference group; p < 0.05. Preoperatively, renal insufficiency (serum creatinine ≥ 2.5 mg/dl or patients on dialysis) was present in four patients (13%) in the single-kidney group and in 21 patients (4%) in the reference group; p < 0.05. In the former group, the unilateral loss of kidney function was secondary to atrophy in 30 patients (94%) and agenesis in two patients (6%). The simple clamp-open distal anastomosis technique was employed in the majority of the cases in the single-kidney group (91%) and in the reference group (83%); p > 0.05. Renal artery endarterectomy or bypass ipsilateral to functioning kidneys was performed on 18 patients (56%) in the single-kidney group and 68 patients (12%) in the reference group; p < 0.05. Renal perfusion with cold Ringer's lactate solution was done in 18 cases (56%) in the single-kidney group and 228 cases (42%) in the reference group; p > 0.05. There was no difference in the operative mortality (9% versus 7%) and the incidence of paraplegia/paraparesis (6% versus 5%) between the single-kidney group and the reference group; p > 0.05. Postoperatively, new onset renal insufficiency developed in 10 patients (31%) in the single-kidney group, and 58 patients (11%) in the reference group; p < 0.05. In the single-kidney group, four patients (13%) had mild renal dysfunction (serum creatinine ≥ 2.5 mg/dl), and two patients (6%) were on dialysis on discharge. Notably, there was no significant difference in the incidence of renal insufficiency on admission compared to the incidence of renal insufficiency on discharge in the single-kidney group (13% versus 19%; p > 0.05). TAAA repair in patients with one functioning kidney can be performed safely. Postoperative renal insufficiency can be managed successfully in the majority of patients.