Thoracoabdominal aortic aneurysm in Cogan's syndrome.

Cogan's syndrome is an autoimmune disease of unknown etiology, clinically manifested as non-syphilitic interstitial keratitis and audiovestibular symptoms. Increasing evidence suggests that Cogan's may be a systemic vasculitis. In this report, we review the vascular manifestations of Cogan's syndrome and report two cases of thoracoabdominal aortic aneurysm in patients with this disorder.     

Thoracoabdominal aortic aneurysm repair after prior aortic surgery

PURPOSE: The purpose of this study was to determine whether the morbidity and mortality of surgery for thoracoabdominal aortic aneurysm (TAAA) in patients with prior aortic surgery are increased. METHODS: The results for all patients undergoing operation for TAAA at a single institution were reviewed. RESULTS: Over a 10-year interval, 279 patients (136 women and 143 men) underwent aortic replacement for TAAA. The mean patient age was 68 years (range, 34-90). The extent of aortic replacement was relatively evenly distributed: type I (91), type II (54), type III (78), or type IV (56). Of these 279 patients, 76 (27%) had undergone prior aortic surgery. Prior infrarenal AAA was the most common prior procedure (56, 20%). Reoperation for prior failed TAAA repair was performed in 20 (7%) patients. A history of Marfan syndrome was highly associated with the need for remedial TAAA procedures (P <.0001). Overall 30-day mortality was 11.4% (32). Mortality was independent of prior aortic surgery (P =.98), prior AAA (P =.84), prior TAAA (P =.61), and gender (P =.18). Postoperative complications were seen in 67 (24%) patients and were more likely in patients who had undergone prior AAA surgery (P =.008). TAAA repair in patients with recurrent TAAA was not associated with higher morbidity (P =.33). Paraplegia (10) occurred in type I (3), type II (2), and type III (5) aneurysms but not in type IV (0), and its development was associated with higher mortality (P =.01). Prior aortic surgery was not found to be predictive of paraplegia (P =.90), although 30% of patients who developed paraplegia had a history of prior AAA repair. CONCLUSIONS: Aortic reoperation for TAAA is required in a significant number of patients, particularly those with Marfan syndrome. Therefore, ongoing surveillance of the residual aorta is mandatory. Postoperative complications are more likely to occur in patients after prior infrarenal aortic replacement, but mortality is not significantly increased. Special technical considerations exist for remedial procedures after failed TAAA repair to provide protection for the spinal cord, kidneys, and viscera. Patients with failed TAAA procedures or progression of aneurysmal extent should be offered reoperation when indicated.     

Thoracoabdominal aortic aneurysm repair. Analysis of postoperative morbidity

Between 1980 and 1986, 101 nondissecting thoracoabdominal aortic aneurysms (TAAAs) were repaired at the Mayo Clinic, Rochester, Minn. Overall mortality was 15% with a 9.6% mortality for elective repair. Nonfatal complications occurred in 44% of patients and included myocardial infarction in 9%, paraplegia in 5%, and renal failure in 4%. In an attempt to reduce morbidity and mortality associated with TAAA repair, one of our vascular surgical services set up a routine protocol of preoperative evaluation, standardized operative technique, and specific guidelines for perioperative management. Fifty-five of the 101 patients underwent elective repair on this service without the use of shunts or bypass. Mortality was reduced to 1.8% and the rate of myocardial infarction was reduced to 1.8%; none of these patients developed renal failure. However, paraplegia/paraparesis still occurred in 5.4% and pulmonary insufficiency occurred in 29%. Preoperative cardiac evaluation and intraoperative reduction of cardiac afterload are important factors in reducing myocardial infarction and death associated with TAAA repair and should be integrated into the management of these patients. However, preexisting pulmonary and renal disease in some patients may limit the surgeon's ability to reduce rates of some complications.     

Thoracoabdominal aortic aneurysm repair in a 15-month-old child.

This case report describes a young child with a thoracoabdominal aortic aneurysm, a very rare condition in pediatrics. The anesthetic management for resection of the aneurysm and repair of the aorta are presented, and special considerations for pediatric patients are discussed.     

Thoracoabdominal aortic aneurysm reconstruction.

Thoracoabdominal aortic reconstruction distal to the left subclavian artery was carried out on 19 patients between 1974 and 1990. Screening procedures to detect cardiac, respiratory or renal impairment were undertaken in all patients. Reconstruction was in the upper third of the descending aorta in 6 patients, middle third in 6 patients, and lower third in 7 patients. The Crawford inclusion technique was used in all cases. There were six deaths, four of which were from the high reconstruction group, and one each from the middle and lower group. Paraparesis occurred in 4 patients, 2 of whom survived with some impairment. Temporary renal failure was seen in 2 patients, liver failure in 2, respiratory failure in 2, sepsis in 1, myocardial infarction in 1, and severe coagulopathy in 3. The perioperative mortality rate was 32% for the group as a whole and 15% for reconstructions which started at the middle or lower thoracic level. We conclude that the mortality rate for the middle and lower reconstructions is acceptable but that alternative techniques for the high aneurysms should be sought.     

Thoracoabdominal aortic aneurysm repair: how I do it.

There remains no consensus on the operative management of Thoracoabdominal aortic aneurysm (TAA). Our approach emphasizes operative expediency and simplicity (without circulatory assist techniques), avoiding anticoagulation and systemic hypothermia. The technique involves a fundamental clamp/sew method with specific adjuncts directed against the principle complications: epidural cooling (introduced in 1993) for spinal cord protection, regional renal hypothermia, and in-line mesenteric shunting to minimize visceral ischemia. In a cohort of over 200 TAA patients (50% Types I & II) treated during the past decade perioperative mortality has been 8% and paraparesis/paraplegia occured in 7%. These figures are halved for patients treated in elective circumstances.     

Thoracoabdominal aortic aneurysm repair through redo left-sided thoracotomy

BACKGROUND: The outcome of thoracoabdominal aortic aneurysm repair through redo-left thoracotomy after operations for descending thoracic aortic aneurysms was investigated. METHODS: Between May 1982 and March 2003, 100 patients underwent thoracoabdominal aortic aneurysm repair in elective surgery without profound hypothermic circulatory arrest. Thirty of these patients had previously undergone operations for descending thoracic aortic aneurysms. To evaluate the influence of previous descending thoracic aortic aneurysm repairs on the results of thoracoabdominal aortic aneurysm replacements, patients were divided into two groups: (1) patients who had previously undergone descending thoracic aortic aneurysm repair (group I; n = 30), and (2) patients who had not previously undergone descending thoracic aortic aneurysm repair (group II; n = 70). RESULTS: The distal aortic perfusion time and operation time were both longer in group I than in group II, but there was no significant difference between the two groups in total selective visceral and renal perfusion time or aortic clamp time. In-hospital mortality rates were 13% in group I and 19% in group II (p = 0.52). Major postoperative complications included paraplegia (10% of patients in group I and 4.3% of patients in group II; p = 0.36), renal failure requiring hemodialysis (20% of patients in group I and 11% of patients in group II; p = 0.35), respiratory failure (30% of patients in group I and 19% of patients in group II; p = 0.22). CONCLUSIONS: Previously descending thoracic aortic aneurysm and redo-left thoracotomy do not adversely affect the outcome of thoracoabdominal aortic aneurysm repair.     

Thoracoabdominal aortic aneurysm repair using a graft with prefabricated branches

A 55-year-old male was referred to our hospital for abdominal examination and was diagnosed as Crawford type III thoracoabdominal aortic aneurysm by computed tomography (CT). Reconstruction of visceral vessels was performed using a Gealweave Coselli Thoracoabdominal Graft, which is currently clinically available. This vascular prosthesis, which is prefabricated 4 branches, requires no intraoperative preparation of the side branches, and the risk of postoperative recurrent aneurysm may be reduced following individual reconstruction of all 4 visceral vessels because of limited remaining aneurismal wall. Therefore, this graft is expected to be useful for this procedure.     

Thoracoabdominal aortic aneurysm combined with aortic occlusion

The case of a 73-year-old woman with aneurysms of the thoracoabdominal aorta and distal arch, combined with aortic occlusion, is reported. Cannulation from the femoral artery was not possible because of the aortic occlusion. Blood supply to the abdominal viscera and lower extremities was achieved only by selective perfusion from the celiac artery, superior mesenteric artery, and bilateral renal arteries. A unique choice of selective perfusion for distal circulatory support is described.     

Thoracoabdominal aortic aneurysm repair: review and update of current strategies

BACKGROUND: Surgical repair of thoracoabdominal aortic aneurysms remains a technically challenging operation that requires a multimodality approach to preventing ischemic complications. The purpose of this report is to update our experience and highlight our current clinical strategies. METHODS: Between January 1, 1986 and December 31, 2001, 1,773 patients underwent thoracoabdominal aortic aneurysm repair. The majority of these patients (1,153, 65%) required Crawford extent I or II repairs. Segmental intercostal or lumbar arteries were reattached in 1,082 patients (61%); left heart bypass was used in 686 patients (38.7%), and 173 patients (9.8%) had cerebrospinal fluid drainage. RESULTS: The 30-day survival rate was 94.3% (1,672 patients). Postoperative complications included renal failure requiring hemodialysis in 105 patients (5.9%) and paraplegia or paraparesis in 79 patients (4.5%). Actuarial 5-year survival was 73.5% +/- 1.6%. CONCLUSIONS: This clinical experience demonstrates that current technical strategies enable patients to undergo thoracoabdominal aortic aneurysm repair with excellent early survival and acceptable morbidity.     

Thoracoabdominal retroperitoneal approach for repair of abdominal aortic aneurysm associated with horseshoe kidney

This article describes a patient with an abdominal aortic aneurysm associated with horseshoe kidney that was repaired through a thoracoabdominal retroperitoneal approach. In general we believe that the retroperitoneal approach is preferable to the standard transabdominal approach since it avoids the two major difficulties associated with aneurysm repair in a patient with a horseshoe kidney. These are the renal artery anomalies which can be reanastomosed from within the aneurysm sac and the renal isthmus anterior to the aorta which is retracted with the kidney.     

Thoracoabdominal aortic aneurysm. How we do it.

A systematic approach to paraplegia risk in the surgical treatment of thoracoabdominal aortic aneurysms based on effective strategies identified from the experimental literature is discussed. With this approach, collateral blood flow, rather than direct intercostal reimplantation, moderate hypothermia and endorphin receptor, is emphasized blockade. The result has been a 10-fold reduction in paraplegia risk in elective patients and a 5-fold reduction in acute patients. This reduction in paralysis risk has resulted in improved short- and long-term survival.     

Thoracoabdominal aneurysm repair: a representative experience.

Between May 1966 and June 1991, 129 patients underwent surgical repair of thoracoabdominal aneurysms, with an overall 30-day mortality rate of 35%. In 75 operations (58%) performed electively, 11 deaths (15%) occurred, and in 54 cases (42%) of either symptomatic or ruptured aneurysms 34 deaths (63%; p less than 0.001) occurred. No one survived among six patients with preoperative hypotension (less than 90 mm Hg) or cardiac arrest. In 16 patients (12%) the etiology of aneurysms was a result of chronic aortic dissection, and the mortality rate in this subgroup was 44%. In the remaining 113 patients (88%) where the etiology was atherosclerosis, 38 deaths occurred (34%; p = 0.433). Spinal cord ischemia occurred in 25 cases (21%) among 116 patients who survived operation. Partial ischemia occurred in six cases (25%), and complete paraplegia occurred in the remainder. Complete and partial paraplegia occurred in 16 of 42 cases (38%) when all of the thoracic aorta was replaced (Crawford groups I, II) and in 9 of 74 cases (12%) when only the abdominal or lower thoracic aorta was replaced (Crawford groups III, IV; p = 0.016). Other complications included myocardial infarction (14 cases, 11%), respiratory failure (46 cases, 36%), and renal failure (33 cases, 27%). The major prospect for improved early survival of patients with thoracoabdominal aneurysms seems to be early detection and elective repair before the occurrence of symptoms.     

Thoracoabdominal aortic aneurysm repair: a prospective cohort study of 121 cases

Between October 1990 and June 2001, 121 patients underwent surgery for thoracoabdominal aortic aneurysm (TAAA)—99 procedures were elective and 22 were for ruptured aneurysms. Between October 1990 and September 1997, the clamp-and-go technique was used for all aneurysms (43 patients), and from October 1997, clamp-and-go was reserved for type IV TAAAs, and atriofemoral bypass (AFB) was used for types I, II, and III (78 patients). Overall hospital mortality was 21.4% (26/121)—12% for the elective group and 64% for the ruptured group. Hospital mortality was associated with age (67 years in survivors vs. 73 years in nonsurvivors, p = 0.03), FEV1<2 L (RR 4.1, p = 0.01), CSF drainage (RR 5.0, p = 0.03), type II aneurysms vs. other aneurysms (RR 3.7, p = 0.02), and relative inexperience (mean rank in the series was 52 in survivors vs. 30 in nonsurvivors, p = 0.01). The overall incidence of neurologic deficits due to spinal cord ischemia was 6.2% (paraplegia in 4.4%). Temporary dialysis was necessary in 13% of patients, and chronic dialysis in 2%. In long-term follow-up of patients undergoing elective repair, 5-year survival was 80% and median survival was 7.9 years. Mortality and neurologic deficits have improved over time as a consequence of either increased surgical experience, the adoption of a protocolized strategy for repair, or secular improvements in ICU care. Long-term survival after elective TAAA repair is excellent.     

EndoSuture aneurysm repair versus fenestrated aneurysm repair in patients with short neck abdominal aortic aneurysm

ObjectiveThe aim of this study was to compare midterm results of EndoAnchors in EndoSuture aneurysm repair (ESAR) versus fenestrated endovascular aneurysm repair (FEVAR) in short neck abdominal aortic aneurysm (AAA).MethodsAll patients who underwent an ESAR procedure for a short neck AAA at our center between September 2017 and May 2020 were considered for analysis. To form the control group, preoperative computed tomography angiography of patients who underwent FEVAR for juxtarenal AAA between April 2012 and May 2020 were reviewed and patients who met short neck criteria selected. A propensity-matched score on neck length and neck diameter was calculated, resulting in 18 matched pairs. AAA shrinkage, type Ia endoleaks (EL), AAA-related reinterventions, and AAA-related deaths were compared.ResultsThe median AAA diameter was 54 mm (interquartile range [IQR], 52-61 mm) versus 58 mm (IQR, 53-63 mm) with a median neck length of 8 mm (IQR, 6-12 mm) vs 10 mm (IQR, 6-13 mm) in ESAR and FEVAR patients, respectively. Technical success was 100% in both groups. Procedural success was 94% in the ESAR group versus 100% in the FEVAR group. The median procedure duration was 138 mm (IQR, 113-182 mm) vs 240 mm (IQR, 199-293 mm) ( P < .001) and the median length of stay was 2 days (IQR, 2-3 days) vs 7 days (IQR, 6-7 days) (P < .001) in ESAR and FEVAR patients, respectively. No major hospital complications were observed in ESAR patients compared with two in FEVAR patients (11%) with one transient acute kidney injury and one transient paraplegia. The median follow-up was 23 months (IQR, 19-33 months) vs 36 months (IQR, 22-57 months) with 67% versus 61% AAA shrinkage in the ESAR and FEVAR groups, respectively (P = .73). No type Ia EL, proximal neck-related reinterventions, or AAA-related deaths were observed in either group. No AAA-related reintervention was observed in the ESAR group versus three reinterventions in the FEVAR group (P = .23).ConclusionsESAR seems to be a safe technique with no major postoperative complications or reinterventions observed during follow-up. It seems to offer similar midterm results as FEVAR in terms of type Ia EL, aneurysm shrinkage, and aneurysm-related mortality. ESAR seems to be a good off-the-shelf alternative to FEVAR in case of technical constraints.