Endovascular repair of para-anastomotic aortic aneurysms

BACKGROUND: Para-anastomotic aneurysms involving the aorta and iliac arteries can occur years after aortic surgery and are at risk for rupture and erosion into surrounding structures. We report on our continued experience with patients who have been treated for these lesions with endovascular management as an alternative to traditional open repair. METHODS: Patients who underwent endovascular repair of para-anastomotic aneurysms involving the distal aortic arch, descending thoracic aorta, abdominal aorta, or iliac arteries were prospectively followed up in a database. Patient comorbidities, initial aortic pathology, initial graft configuration, aneurysm characteristics, evidence of infection, type and configuration of endograft used, and follow-up were analyzed. RESULTS: From 1997 to 2006, 53 patients with 65 para-anastomotic aneurysms were treated with endovascular stent grafts. Patients who were originally treated for aortoiliac occlusive disease presented significantly later than those treated for aneurysmal disease (15.8 vs 8.9 years, P < .01) The initial technical success rate was 98%. Endoleaks were identified in six patients (11%) < or =1 month of surgery, and three required reintervention, including open conversions. Endoleak complications were significantly associated with patients who had symptomatic para-anastomotic aneurysms (P = .01). Perioperative mortality after endovascular repair was 3.8%. Overall mortality within a mean follow-up of 18 months was 49% and was significantly associated with older age at the time of endovascular treatment (P = .03). CONCLUSION: Endovascular repair of para-anastomotic aneurysms involving the aorta and iliac arteries is technically feasible and is associated with a low perioperative morbidity and mortality. Close follow-up is required to identify endoleaks. Long-term survival is limited in older patients. We recommend endovascular stent graft repair for para-anastomotic aneurysms in anatomically suitable patients.     

Factors affecting long-term mortality after endovascular repair of abdominal aortic aneurysms

HYPOTHESIS: Endovascular repair of abdominal aortic aneurysms has made considerable advancements with respect to perioperative mortality. However, fewer data are available regarding factors affecting long-term mortality, including the impact of adverse perioperative cardiac events. Perioperative clinical cardiac risk factors are significant predictors of long-term mortality.Design, Setting, and PATIENTS: Retrospective review of a prospective database of 468 patients who underwent endovascular abdominal aortic aneurysm repair from June 3, 1996, to January 31, 2005. MAIN OUTCOME MEASURES: Preoperative, intraoperative, and postoperative factors were analyzed using multivariate Cox proportional hazards models to identify statistically significant independent predictors of long-term survival (beyond 30 days and after discharge from the hospital). RESULTS: The mean age was 74 years, and 90% of the patients were male. Median follow-up was 2.57 years (interquartile range, 0.92-4.06 years). The leading cause of death was cardiac in nature. On multivariate analysis, the number of preoperative clinical cardiac risk factors (P < .001), spending 2 or more days in the intensive care unit (P < .001), and having an ST-segment elevation myocardial infarction (P < .001) were predictors of decreased long-term survival. Of note, having a perioperative non-ST-segment elevation myocardial infarction was not predictive of decreased survival (P = .09). CONCLUSIONS: Adverse cardiac events are the leading cause of long-term mortality following endovascular repair of abdominal aortic aneurysms. Preoperative clinical cardiac risk factors are significant predictors of long-term mortality, as are a prolonged intensive care unit stay and a perioperative ST-segment elevation myocardial infarction. A perioperative non-ST-segment elevation myocardial infarction did not influence long-term outcome.     

Early outcomes after elective and emergent endovascular repair of the thoracic aorta

BACKGROUND: Endovascular treatment of thoracic aortic pathology has emerged as a viable alternative to open surgical repair in both the elective and emergent settings. The aim of this study was to evaluate preoperative work-up, intra-operative strategy, and outcomes of endovascular stent-grafting of the thoracic aorta in patients undergoing elective repair and those undergoing emergent repair. METHODS: All patient information was obtained by a retrospective review of an established clinical database for all endovascular thoracic stent-graft cases. From October 1999 to August 2005, 70 patients were treated with endovascular stent-grafts for lesions of the thoracic aorta. Thirty-five patients had an elective endovascular procedure, and 35 patients had an emergent procedure. RESULTS: Thirty-five patients in the endovascular (EL) group were treated for aneurysm (n = 34) and type B dissection (n = 1). Thirty-five patients in the emergent (EM) group were treated for aneurysm (n = 10), intramural hematoma (n = 10), type B dissection (n = 7), traumatic rupture (n = 7), and aortoesophageal fistula (n = 1). Preoperative angiography was performed in 94.3% (33/35) of EL patients but in only 45.7% (16/35) EM patients (P < .005). The EM procedures had significantly shorter operative times, used lower contrast volumes, used fewer stent-graft components (mode 2, range 1 to 5 vs mode 1, range 1 to 3; P = .02), and spinal cerebrospinal fluid drains were used significantly less often (82.9% vs 57.1%, P = .04). Both groups had similar 30-day morbidity, mortality (0/35 EL vs 1/35 [2.9%] EM, P = .99), postoperative endoleak (9/35 [25.7%] EL vs 7/35 [20.0%] EM, P = .78), endovascular failure (3/35 [8.6%] EL vs 5/35 [14.3%] EM, P = .71), and patient survival. CONCLUSION: There are significant differences in the underlying pathology, preoperative evaluation, and operative course between elective and emergency treatment endovascular procedures for lesions of the thoracic aorta. Endovascular repair of thoracic aortic lesions can be accomplished with low perioperative mortality and morbidity rates, as well as acceptable endoleak and endovascular failure rates for both elective and emergency procedures.     

Stent-graft versus open-surgical repair of the thoracic aorta: mid-term results

OBJECTIVE: Pivotal and comparative trial data are emerging for stent graft (SG) vs open repair of the thoracic aorta. We reviewed procedure-related perioperative morbidity, mortality, and mid-term outcomes in a contemporary series of patients treated with SG of the thoracic aorta. The data were compared with those of a patient cohort concurrently treated with open surgical repair confined to the descending aorta. METHODS: A review of patients undergoing SG procedures and open surgery of the thoracic aorta from January 1, 1996, to November 30, 2005, was performed from a prospectively compiled database. Study end points included perioperative complications, late survival, freedom from reinterventions, and graft-related complications. Multivariate methods were used to assess variables potentially associated with study end points; late outcomes were compared with actuarial methods. RESULTS: In 105 patients (mean age, 70 years; 66 male [62.9%]) SG repairs were done for 68 degenerative aneurysms (64.7%), 12 penetrating ulcers (11.4%), 15 pseudoaneurysms (14.3%), 9 traumatic tears (8.6%), and 1 acute dissection (0.9%). Mean follow-up was 22 months (range, 0 to 101 months). Eighty-nine (84.8%) SG patients were asymptomatic at presentation and underwent elective repair, whereas 16 (15.2%) presented with acute conditions and underwent urgent repair. Perioperative mortality was 7.6% (8/105), and actuarial survival at 48 months was 54% +/- 7%. The perioperative mortality rate among SG patients treated for degenerative pathology was 10.4% (8/77). Seven (6.7%) of 105 patients experienced spinal cord ischemic complications, including 2 patients with transient paraparesis that resolved by the time of discharge. Reinterventions were performed in 10.5% of patients (11/105), with freedom from reintervention approaching 81% by 48 months. Over the same interval, 93 patients were treated with open-surgical repair for descending thoracic aneurysm (anastomosis cephalad to the celiac axis). Perioperative mortality in the open cohort was 15.1% (14/93; P = .09 vs SG repair), and the 48-month actuarial survival was 64% +/- 6%. The incidence of spinal cord ischemic complications was 8.6% (8/93), including 4 patients with transient paraparesis (P = .44 vs SG repair). Nine patients (9.7%) required surgical reintervention during the follow-up period, with 48-month freedom from reintervention approaching 79% (P = .73 vs SG repair). CONCLUSIONS: Operative mortality was halved with SG, with similar late survival for both cohorts. Reinterventions were required at a nearly identical rate for open repair and SG, and both groups experienced similar rates of spinal cord ischemic complications.     

Management Trends and Early Mortality Rates for Acute Type B Aortic Dissection: A 10-Year Single-Institution Experience

This study was undertaken to assess trends in management over time and to determine predictors of early mortality for acute type B aortic dissection. Fifty-three consecutive patients with acute type B aortic dissection over a 10-year period were reviewed. Baseline demographics as well as in-hospital data regarding symptoms, type of initial management, surgical indications, type of surgical intervention, and early mortality rates were collected. Independent predictors of early mortality were determined by logistic regression. Forty-one of 53 (77.4%) patients were initially managed medically with a total of 26 (49.1%) ultimately undergoing surgical repair during hospitalization. Crude early mortality was 30.8% in the surgical group vs. 14.8% in the medical group (p = 0.20). Improvements in early mortality were observed over time for surgery (58.3%, first half vs. 7.1%, second half; p = 0.019) and medical therapy (21.4%, first half vs. 7.7%, second half; p = 0.64). Early mortality was 50% in 16 patients having open aortic surgery vs. 0% in 10 patients undergoing endovascular stent graft repair (p < 0.005). Independent predictors of early mortality included only renal dysfunction (odds ratio [OR] 7.39), aortic rupture (OR 8.72), and date of admission during the study period (OR 0.712). Despite improvements over time in early mortality that appear associated with the increasing use of endovascular stent grafts, patient-specific factors are still the most important independent predictors of early mortality in acute type B aortic dissection.Presented at the Twenty-eighth Annual Meeting of the Peripheral Vascular Surgery Society, Chicago, IL, June 7, 2003.     

Thoracic endovascular repair versus open surgical repair — which is the more cost-effective intervention for descending thoracic aortic pathologies?

Objective: Endovascular treatment is increasingly used to treat complicated aortic pathology. The aim of the study was to assess if compared with operative repair, thoracic endovascular repair of aorta (TEVAR) was associated with a cost benefit in management of diseases affecting the descending thoracic aorta. We also compared early and mid-term outcomes between the two groups. Methods: Clinical characteristics, outcomes and hospitalisation costs of 84 consecutive patients undergoing intervention for conditions affecting the descending thoracic aorta were reviewed retrospectively. Hospitalisation costs were calculated from National Health Service (NHS) reference costs for staff time, consumables, transfusion and length of stay. Results: Apart from a higher frequency of acute type B dissection (16/45 vs 5/39, p = 0.047) in the TEVAR group, the baseline characteristics were similar. TEVAR was associated with significant reductions in morbidity (renal dysfunction 11 (31%) vs 5 (10%) p = 0.025; in-hospital death 7 (20%) vs 3 (6%), p = 0.03; median intensive therapy unit (ITU) stay 6 (3–11) vs 1 (1–4), p < 0.0001). TEVAR was associated with significantly increased procedural costs (£2468 (€2961) vs £9581 (€11495) p ≤ 0.0001). This was chiefly attributable to the cost of endovascular stents. There was no significant difference in overall hospitalisation costs. TEVAR was associated with significantly lower freedom from death or re-operation (log rank p = 0.048). Conclusions: TEVAR is associated with reduced morbidity and mortality in the short term. However, no cost benefit was seen with TEVAR even in the short term. In the long term, due to increased risk of re-interventions TEVAR may actually prove to be a more expensive therapeutic option.     

Stent versus open surgery for acute and chronic traumatic injury of the thoracic aorta: a single-center experience

BACKGROUND: Traumatic injuries of the thoracic aorta have a high morbidity and mortality. Treatment options include either open surgery or endovascular stent graft implantation. METHODS: We have reviewed retrospectively all our patients treated for acute and chronic traumatic injury of the thoracic aorta and compared the outcome of the endovascular versus open therapy. Age, gender, severity of injuries, interventional delay, perioperative morbidity, 30-day mortality, length of intensive care, and overall hospital stay were evaluated. RESULTS: In all, 46 patients were treated over the past 14 years. Overall 30-day mortality was 16% in patients treated for acute or contained aortic ruptures (n = 31) and not significantly different after endovascular versus open repair (13.3% versus 18.8%). There was no mortality in the patients receiving elective stent grafting or open surgery for chronic posttraumatic aortic aneurysms (n = 15). Conversion and/or operative revision following stent graft implantation occurred in three patients (12.5%). Neurologic complications were absent in the stent graft group (0 of 24), whereas paraplegia (n = 2) or minor neurologic (n = 3) deficits developed following open surgery (5 of 22; 22.7%; p = 0.013). Length of intensive care and overall hospital stay were significantly shorter for patients after elective stent graft treatment compared with open surgery (p = 0.045). CONCLUSIONS: According to our midterm results, minimally invasive endovascular repair for patients with acute traumatic ruptures and chronic posttraumatic aneurysms is an equally effective treatment option compared with open surgery, with advantages regarding perioperative neurologic complications and duration of hospital stay under elective circumstances.     

Outcomes of surgical and endovascular treatment of acute traumatic thoracic aortic injury

BACKGROUND: Acute thoracic aortic injury resulting from blunt trauma is a life-threatening condition. Endovascular therapy is a less invasive treatment modality that may potentially improve patient outcomes. We reviewed our experience with patients who sustained blunt thoracic aortic injuries distal to the left subclavian artery and presented for open surgical or endovascular repair. METHODS: Between August 1993 and August 2006, 62 patients sustained blunt thoracic aortic injuries distal to the origin of the left subclavian artery and proceeded to undergo open surgical (n = 48, 77%), or endovascular repair (n = 14, 23%). Revised trauma score (RTS), injury severity score (ISS), new injury severity score (NISS), individual associated traumatic injuries, as well as operative and postoperative outcomes were compared between open surgical and endovascular groups. RESULTS: Age, gender, race, and mechanism of injury did not differ between open surgical and endovascular groups. Additionally, RTS, ISS, and NISS values were not significantly different. The proportion of patients with sternal fractures (14% vs 0%), or unstable spinal fractures (36% vs 10%) was significantly greater in the endovascular group. Of the patients who received endografts, 93% (n = 13) were evaluated by a cardiothoracic surgeon and assessed to be prohibitive to operative intervention. Endografts utilized included commercially manufactured thoracic endografts (n = 6; 43%) and abdominal aortic endograft components (n = 8; 57%). Forty-one interposition grafts were placed in the open surgical group. Renal complications (32% vs 7%), and urinary tract infections (35% vs 7%) approached significance between surgical and endovascular groups (P = .082 and P = .077, respectively). Intraoperative mortality for the surgical and endovascular groups was 23% and 0%, respectively (P = .056). Endovascular repair was associated with significant reductions in operative time (118 vs 209 minutes), estimated blood loss (77 vs 3180 ml), and intraoperative blood transfusions (0.9 vs 6.1 units). No endoleaks were detected during a mean follow-up of 9.4 months in the endovascular group. CONCLUSION: Endovascular repair of blunt descending thoracic aortic injuries utilizing thoracic or abdominal endographs is a technically feasible modality that is at least equivalent to open therapy in the short term and associated with a lower intraoperative mortality (P = .056). Endovascular therapy has advantages in operative time, operative blood loss, and intraoperative blood transfusions.     

Contemporary results of open repair of ruptured descending thoracic and thoracoabdominal aortic aneurysms

OBJECTIVE: The purpose of this study was to evaluate the results of open repair for ruptured descending thoracic and thoracoabdominal aortic aneurysm (RDTAA). METHODS: A retrospective review identified 41 consecutive cases of open surgical repair in 40 patients presenting with nontraumatic, atherosclerotic RDTAA from 1996 to 2006. Patients with traumatic injuries or complicated dissections were excluded. Patient characteristics and preoperative, intraoperative, and postoperative variables were collected from the medical record. Univariate and logistic regression were used to identify factors contributing to mortality and morbidity in these patients. RESULTS: The operative mortality rate was 26.8% (11/41). All but two deaths occurred within 24 hours of operation; seven were intraoperative. Overall actuarial survival rates at 1 and 2 years were 53.7% and 47.1%, respectively. For those who survived to hospital discharge, the respective numbers were 73.3% and 64.4%. Intraoperative hypotension and blood transfusion requirements were independent predictors of perioperative death. Octogenarians had a mortality rate equivalent to that of the younger population (25% vs 27.6%; not significant). There was a strong trend toward an improved outcome in the latter part (2003-2006) compared with the first part (1995-2002; 13.6% vs 42.1%, respectively; P = .075). CONCLUSIONS: Direct open repair for RDTAA can be achieved with acceptable mortality and morbidity rates even in elderly patients. Improved outcome can be expected with increased volume and experience. This series should help establish a reference against which the results of endovascular endeavors and hybrid procedures could be compared.     

Endovascular repair of the descending thoracic aorta: evidence for the change in clinical practice

The purpose was to review outcome data following endovascular repair of the descending thoracic aorta from reports published between 1994 and 2004. To accomplish this task, 1,518 patients underwent endovascular repair for thoracic aortic disease; 810 thoracic aortic aneurysms, 500 type B thoracic aortic dissections, and 106 traumatic ruptures. The 30-day mortality rate was 5.5% and 6% for late postoperative deaths. The primary technical success rate was 97%, with only 15 patients requiring open conversion. Neurologic deficits occurred in 29 patients. In total, 118 endoleaks were reported; 29 were restented, and the remainder required surgical intervention. Graft infection occurred in 6 cases, and migrations were detected in 10. The conclusion reached is that endovascular repair of descending thoracic aortic disease is feasible and can be achieved with low rates of perioperative morbidity and mortality. As few long-term data exist on the durability of thoracic stent grafts, lifelong surveillance remains necessary.     

Endovascular Repair of Nontraumatic Ruptured Thoracic Aortic Pathologies

Endovascular repair of ruptured infrarenal abdominal aortic aneurysms (AAA) is receiving increased attention as the number of experienced users increases. Development of thoracic aortic stent grafts has lagged behind infrarenal advancements because of the reported prevalence of disease. In a few centers, however, the experience in performing thoracic stent graft procedures is quite substantial, such that endovascular therapy has been applied to ruptured thoracic aortic pathologies even though data remain limited and this novel therapy remains controversial. We report our combined experience with endovascular repair of ruptured thoracic aneurysms (RTA) and ruptured thoracic dissections (RTD). One hundred eighty-four thoracic stent graft procedures at the University of North Carolina (UNC) and Union Memorial Hospital (UMH) were reviewed and those patients undergoing RTA or RTD repair from January 1, 2000 to December 31, 2003 identified. Patients having procedures for elective repair or aortic transections were excluded from the analysis. Patient presentation, preoperative condition, procedural variables, mortality, and morbidity were examined. Seventy-four percent of the collective procedures were undertaken in high-risk patients (UNC, 38 of 40; UMH, 99 of 144). Twenty-two patients (8.7%; UNC, n = 6; UMH, n = 16) underwent treatment for either an RTA (n = 11) or an RTD (n = 11). The average age of this cohort was 66.5 ± 15.6 years and the average aneurysm diameter was 73.1 ± 31.4 mm. The mean duration of symptoms prior to repair was 103.1 ± 122 hr, influenced primarily by transport times and device availability. Stent graft exclusion was accomplished in 100% of patients with a procedural mortality of 0%. Commercial Talent devices were used in 19 patients (86.4%) and AneuRx device was used in 1 patient (4.5%). In the remaining two (9.1%) patients handmade devices constructed of Gianturco stents and Dacron fabric were used because of active hemorrhage and lack of appropriate device sizes. Operative time was 135.5 ± 48.5 min and was associated with an average blood loss of 242.0 ± 232.4 cc. Thirty-day mortality was 45.5% (RTA, 27.3%; RTD, 63.6%; p = 0.099). Length of stay in the intensive care unit was 6.1 ± 7.9 days and the mean hospital stay was 11.7 ± 10.6 days. Major complications were present in 54.5% of RTA (cardiac, 1; pulmonary, 3; cardiovascular accident, 2; spinal cord ischemia, 2; pulmonary embolism, 1), and 81.2% of RTD (multisystem organ failure, 7; pulmonary, 1; common femoral artery injury, 1) but not statistically different between groups. There were only two late complications (cardiac death, endoleak-Ia, 1) that occurred during the mean follow-up of 12.5 ± 11.3 (range, 1-32) months. These results indicate that endovascular repair of ruptured thoracic pathologies can be accomplished with an acceptable morbidity and mortality. There were no immediate procedural mortalities and complete exclusion was accomplished in all patients. Most postoperative complications arose from preexisting medical conditions and were not procedure related. The benefit of endovascular repair of ruptured thoracic aortic pathologies is promising.Presented at the Twenty-ninth Annual Meeting of the Peripheral Vascular Society, Anaheim, CA, June 4–5, 2004.     

Spinal cord ischemia after elective stent-graft repair of the thoracic aorta

OBJECTIVES: Neurologic deficit after endovascular treatment of the thoracic aorta is a complication reported with variable frequency that may be associated with severe morbidity and mortality. The mechanism of spinal cord ischemia appears to be multifactorial and remains ill-defined. We reviewed our experience to investigate the determinants of paraplegia after stent-graft repair of the thoracic aorta, identify patients at risk, and assess the effectiveness of ancillary techniques. METHODS: Over a 5-year period (June 1999 to December 2004), 103 patients underwent elective endovascular repair of the thoracic aorta at a university referral center. Indications for treatment were atherosclerotic aneurysms in 88 patients, chronic type B dissection in 10 patients, and penetrating aortic ulcer in 5 patients. Four of the 103 patients affected with thoracoabdominal aortic aneurysms had hybrid procedures and were excluded from the cumulative analysis. Twelve patients with zone 0 and zone 1 aortic arch aneurysms were operated on with synchronous or staged surgical aortic debranching. Preoperative cerebrospinal fluid (CSF) drainage was instituted in seven selected patients. Neurologic deficits were assessed by an independent neurologist and classified as immediate or delayed. Patient demographics and perioperative factors related to the endovascular procedure were evaluated by using univariate statistical analyses. RESULTS: A primary technical success was achieved in 94 patients (94.9%). At a mean follow-up of 34 +/- 14 months, a midterm clinical success was obtained in 90 patients (90.9%). Four patients (4.04%) had delayed neurologic deficit that completely resolved after the institution of CSF drainage, steroids administration, and arterial pressure pharmacologic adjustment. None of the four patients who underwent hybrid procedures for thoracoabdominal aortic aneurysms had paraplegia or paraparesis. Univariate analyses identified only a perioperative lowest mean arterial pressure (MAP) of <70 mm Hg as a significant risk factor (P < .0001). CONCLUSION: Perioperative hypotension (MAP <70 mm Hg) was found to be a significant predictor of spinal cord ischemia; hence, careful monitoring and prompt correction of arterial pressure may prevent the development of paraplegia. When the latter occurred, reduction of the CSF pressure by drainage was useful. Patients with a previous or synchronous abdominal aortic repair may also benefit from CSF drainage as a perioperative adjunct.     

Early outcomes of thoracic endovascular stent-graft repair for acute complicated type B dissection using the Gore TAG endoprosthesis

We assessed the technical success and early outcome of thoracic endovascular aortic repair (TEVAR) for complicated acute type B thoracic aortic dissection treated at a single institution using a commercially available device. All patients with symptomatic complicated acute type B thoracic aortic dissection treated with TEVAR since Food and Drug Administration approval of the Gore (Flagstaff, AZ) TAG endoprosthesis were identified from a prospectively maintained vascular registry. Clinical indications, operative technique, perioperative complications, follow-up imaging, and mortality were analyzed. Between March 2005 and November 2007, 127 TEVARs using the TAG endoprosthesis were performed, of which 15 (11.8%) were for complicated acute type B thoracic aortic dissection. Indications for repair were malperfusion (53%), persistent pain (27%), and primary aortic failure (33%). Technical feasibility and success with deployment proximal to the entry tear was 93.3%, requiring at least partial coverage of the left subclavian artery in seven (46.7%). Adjunctive procedures required at the time of TEVAR included renal stent (n = 2), iliac stent (n = 3), and access-artery open repair (n = 2). Twelve patients (80%) had immediate resolution of the malperfusion deficit. Major perioperative complications included paraplegia (13.3%), renal failure requiring hemodialysis (13.3%), and stroke (6.7%). Perioperative mortality was 13.3%, occurring in one patient presenting with rupture and one with profound heart failure on admission. For complicated acute type B thoracic aortic dissection, TEVAR using commercially available stent grafts showed high technical success, excellent results at resolving malperfusion, and acceptably low complications and perioperative mortality.     

Thoracoabdominal Aneurysm Repair: Spinal Cord Protection Using Profound Hypothermia and Circulatory Arrest

Between January 1991 and February 1993,14 patients (11 male, 3 female) between 21 and 79 years of age (median 50 years) underwent reconstruction of the thoracic (n = 7) and thoracoabdominal aorta (n = 7). Four patients had previously undergone operation of the ascending aorta, and In three patients coronary artery bypass grafting had previously been performed. All patients were operated on via a posterolateral thoracotomy using cardiopulmonary bypass wlth continuous blood cardloplegla and hypothermlc circulatory arrest (11 °C naso-pharyngeal temperature, flat-EEG). All patent lower intercostal and lumbar arteries (T3 to L5) were reimplanted. The 30-day mortality after repair of the thoracic aorta was 0%; after replacement of the thoracoabdomlnal aorta, mortality was 28.5% (n = 2). One patient died 70 days after replacement of the thoracic aorta as a consequence of a perioperative stroke. None of the surviving 11 patients developed a permanent neurological deficit or renal or cardiac dysfunction. The average Intensive care stay was 6 days for patients after replacement of the thoracic aorta and 18 days for patients after replacement of the thoracoabdominal aorta. Our results suggest that use of elective hypothermia and circulatory arrest for spinal cord protection is highly effective. We, therefore, recommend this method for complex reconstructions of the thoracoabdominal aorta. (J Card Surg 1994;9:679–684)     

Early and long-term results of replacement of the descending aorta.

OBJECTIVES: The aim of this analysis was to evaluate our results of open surgery on the descending thoracic aorta as benchmark to define indications for endovascular treatment. METHODS: Between January 1981 and December 2000, 115 patients underwent replacement of the descending or thoraco-abdominal aorta. Follow-up to 20 years was complete in 98%. RESULTS: Early mortality was 19% and paraplegia rate was 7%. Surgery before 1990 and coronary artery disease were independent predictors for early mortality. Thoraco-abdominal repair and normothermia were independent predictors for paraplegia. Ten years survival rate was 63%. CONCLUSIONS: Our results confirm that replacement of the descending aorta can be performed today with acceptable low mortality and morbidity and with consistent exclusion of the aneurysm or dissection. Long-term results of endovascular stent-grafts in the descending aorta are unclear. In our opinion endovascular stent-grafts should be reserved for high risk patients, acute dissection or acute aortic rupture.     

Myocardial damage in high-risk patients undergoing elective endovascular or open infrarenal abdominal aortic aneurysm repair.

OBJECTIVE: Dobutamine stress echocardiography (DSE) provides an objective assessment of the presence and extent of coronary artery disease. Therefore we compared cardiac outcome in patients at high-cardiac risk undergoing open or endovascular repair of infrarenal AAA using preoperative DSE results. METHODS: Consecutive patients with >or=3 cardiac risk factors (age >70 years, angina pectoris, myocardial infarction, heart failure, stroke, renal failure, and diabetes mellitus) undergoing infrarenal AAA repair were reviewed retrospectively. All underwent cardiac stress testing using DSE. Postoperatively data on troponin release and ECG were collected on day 1, 3, 7, before discharge, and on day 30. The main outcome measures were perioperative myocardial damage and myocardial infarction or cardiovascular death. RESULTS: All 77 patients (39 endovascular, 38 open) had a history of cardiac disease. The number and type of cardiac risk factors were similar in both groups. Also DSE results were similar: 55 vs 56%, 24 vs 28%, and 21 vs 18% had no, limited, or extensive stress induced myocardial ischemia respectively. The incidence of perioperative myocardial damage (47% vs 13%, p=0.001) and the combination of myocardial infarction or cardiovascular death (13% vs 0%, p=0.02) was significantly lower in patients receiving endovascular repair. CONCLUSION: In patients with similar high cardiac risk, endovascular repair of infrarenal aortic aneurysms is associated with a reduced incidence of perioperative myocardial damage.     

An analysis of standard open and endovascular surgical repair of abdominal aortic aneurysms in octogenarians

While elective open abdominal aortic aneurysm (AAA) repair has been shown to be safe in selected octogenarians, very little is known about the role of endovascular AAA exclusion in this high-risk cohort. A retrospective review of our vascular surgical registry from January 1996 to December 2001 revealed 51 octogenarians that underwent infrarenal AAA repair. Since 1999 all octogenarians who presented for AAA repair were evaluated for preferential endovascular stent graft placement. Over the 6-year period, 35 patients underwent standard open repair while 16 patients were found to be anatomic candidates for and were treated with an endovascular stent graft. Hospital and office charts were reviewed to compare the endovascular cohort to the standard open cohort. Factors considered included patient comorbidities, perioperative data, and operative outcomes. Statistical analysis was done using Wilcoxon rank sum test and Fisher exact test. The median age for the entire group was 83 years. There were 11 females in the open group and 1 female in the endovascular group. There were no statistically significant differences in preoperative patient comorbidities between groups. Total mortality for the entire series was 11.8 per cent but this included 5 ruptured AAAs, all of which patients died, and 11 additional AAAs that were symptomatic, of which 1 patient died. Total nonruptured mortality for the entire series was 2.2 per cent (0% for the endo-group and 3.3% for the open group). There were statistically significant differences between the endovascular versus the open groups when comparing aneurysm diameter (5.6 cm vs. 6.2 cm; P = 0.016), estimated blood loss (225 cc vs. 2100 cc; P < 0.001), ICU days (0 vs. 3; P < 0.001), length of hospital stay (2 days vs. 12 days; P < 0.001), and patients with blood transfusions (1 vs. 27; P < 0.001). When comparing postoperative morbidities, 4 of the endovascular patients (25%) and 25 of the open patients (68.6%) had a complication (P = 0.006). In conclusion, endovascular stent graft treatment of nonruptured infrarenal AAAs in octogenarians led to significantly better outcomes and should probably be considered the preferred treatment whenever anatomically appropriate. Endovascular exclusion of ruptured AAAs may potentially improve future outcomes in this high-risk group.     

The role of preoperative radionuclide left ventricular ejection fraction for risk assessment in carotid surgery

Radionuclide ejection fraction (EF) and ventricular wall motion were determined in 73 patients before 82 carotid operations (79 carotid endarterectomies [CEAs] and three cervical carotid-subclavian bypasses). The EF was 55% +/- 13%, ranging from 21% to 77%. Thirty-three percent (24/73) had low EF (less than or equal to 50%), and 44% (28/63) had myocardial wall motion abnormalities. Perioperative cardiac complications, including myocardial infarction (MI), new ventricular arrhythmia, or severe congestive heart failure, were present after 12.2% (10/82) of the operations. Perioperative MI was present in 4.9% (4/82); in 50% of these it was fatal. Perioperative (30-day) stroke was present in 2.5% (2/79) of those undergoing CEA. Life table analysis revealed overall survival was lower in patients with EF of 35% or less vs those with EF over 35% during follow-up (522 +/- 280 days). Perioperative cardiac complications were more frequent with EF of 35% or less, occurring in 43% (3/7) vs 9% (7/75) of cases with EF over 35%. There was no statistical difference in perioperative mortality, but cumulative mortality differed, being 57% (4/7) in those with EF of 35% or less vs 11% (7/66) in patients with EF over 35%. Patients with EF of 35% or less are at increased risk for perioperative cardiac complications and reduced overall survival following carotid surgery.     

Characteristics of patients at risk for perioperative myocardial infarction after infrainguinal bypass surgery: An exploratory study

Patients requiring infrainguinal bypass surgery often have diffuse atherosclerotic disease, and perioperative myocardial infarction (MI) is a potentially lethal complication that is not uncommon in these patients. To establish additional clinical characteristics that might be useful in identifying patients who require more extensive cardiac evaluation, we conducted an exploratory case-control study comparing 22 patients who had a perioperative MI following elective infrainguinal bypass surgery with 191 control subjects whose bypasses were uneventful. In addition to previously recognized risk factors (e.g., history of angina or prior MI), we examined the association of perioperative MI with (1) results of common preoperative laboratory tests and ECG, (2) preoperative use of certain medications, and (3) intraoperative factors that might be anticipated prior to surgery (e.g., duration of surgery or type of anesthesia). Perioperative MI was associated not only with a history of angina, prior MI, or coronary artery disease but also with the need for certain cardiac medications, higher white blood cell (WBC) counts, ST-segment depression, left bundle branch block, and lengthy surgical procedures. Multiple logistic regression analysis identified the following factors as being independently associated with perioperative MI: preoperative antiarrhythmic agents (odds ratio [OR]=26.4,p 0.006), nitrates (OR=8.4,p=0.006), calcium channel blockers (OR=5.5,p=0.04), and aspirin (OR=6.8,p <0.01) and ST-segment depression (OR=11.8,p=0.01), WBC count (OR=1.27/1000,p=0.005), and duration of surgery (OR=2.2/hr,p=0.0001). In patients undergoing infrainguinal bypass surgery, perioperative MI is associated not only with a history of previous cardiac events and ECG evidence of ischemia but also with regular use of certain cardiac medications, higher WBC counts, and longer surgical procedures. Incorporation of these variables into current methods of risk assessment might improve their predictive value sufficiently to provide an objective, inexpensive means of distinguishing patients who warrant extensive preoperative cardiac evaluation from those who do not.We are indebted to Maryann Barry, RN, for helping to collect the preoperative ECG reports and to Timothy Heeren, PhD, Boston University School of Public Health, for advice regarding statistical analysis.     

Urgent carotid endarterectomy is safe in patients with few comorbid medical conditions

Recent reports from single institutions have confirmed the efficacy of carotid endarterectomy (CEA) performed in the urgent or emergent setting, although with higher perioperative mortality and morbidity. We determined the results of urgently performed CEA in academic and community hospitals and whether patient or hospital factors affected outcome. The records of patients undergoing CEA in all nonfederal hospitals in the state of Connecticut between 1992 and 2002 were reviewed, and symptomatic patients who presented in an urgent or emergent fashion were compared to patients treated electively. Multivariable logistic regression was used to determine the effect of patient risk factors on perioperative mortality, stroke, and cardiac complications. Patients undergoing urgent CEA (n = 764, 6.3%) had higher perioperative mortality (2.0% vs. 0.3%, p < 0.0001) and stroke (2.9% vs. 1.1%, p < 0.0001) but not cardiac complications (3.0% vs. 2.2%, p = 0.14) compared to patients undergoing elective CEA (n = 11,312). Patients undergoing urgent CEA and with high rates of associated comorbidity had a higher risk of perioperative mortality (7.8% vs. 0.4, p = 0.001), stroke (10.9% vs. 0.8%, p = 0.0002), and cardiac complications (14.1% vs. 0.8%, p < 0.0001) compared to patients presenting urgently but with little comorbidity. Perioperative mortality was associated with performance of the procedure in hospitals with low bed capacity (odds ratio [OR] = 4.6, p = 0.01). Perioperative stroke was associated with renal insufficiency (OR = 5.3, p = 0.04). Perioperative cardiac complications were associated with diabetes (OR = 2.6, p = 0.03) and performance in hospitals with low bed capacity (OR = 5.0, p < 0.01). Urgent admission was associated with age >/=80 (OR = 1.2, p = 0.04), renal disease (OR = 1.8, p = 0.05), and cardiac disease (OR = 1.3, p < 0.01). Urgently performed CEA has higher perioperative mortality and stroke compared with electively performed cases. However, the subset of patients with low rates of associated comorbid medical conditions but urgently needing CEA is associated with low rates of perioperative complications. Patients with severe associated comorbid medical conditions who present urgently for CEA may form a high-risk group of patients to be considered for referral to large treatment centers or possibly alternative therapy.