Preservation of intercostal arteries during thoracoabdominal aortic aneurysm surgery: a retrospective study.

OBJECTIVE: The purpose of this article was to examine the influence of reimplantation of patent intercostal and lumbar arteries on the incidence of postoperative paraplegia/paraparesis in patients undergoing clamp-and-sew surgical repair of thoracoabdominal aortic aneurysms. METHODS: Data from January 1987 through December 1997 were retrospectively collected on 132 patients. Ninety-one patients in group I underwent aneurysm repairs before January 1995 and did not undergo intercostal artery reimplantation. Group II included the more recent 41 patients who had vessels between the eighth thoracic intercostal and the second lumbar arteries reimplanted to the graft or preserved at the aortic anastomoses. RESULTS: The operative mortality rate was 13.2% (12/91) in group I and 4.9% (2/41) in group II (P =.22). The incidence of postoperative paraplegia was significantly lower in the more recent cohort of patients (8.8% [8/91] in group I vs 0% [0/41] in group II, P =.05). The overall rate of spinal cord dysfunction was lowered from 9.9% (9/91) in group I to 2.4% (1/41) in group II (P =.17). However, a multivariable logistic regression analysis identified only aneurysm extent (Crawford type I and type II) as a predictor of less postoperative spinal cord injury (P =.08). The average aortic crossclamp time in group I was 30.3 +/- 11.5 (SD) minutes, and the time of aortic occlusion in group II was not significantly prolonged, with an average crossclamp time of 31.0 +/- 21.0 (SD) minutes (P =. 88). CONCLUSIONS: An aggressive approach to maintain intercostal artery patency during clamp-and-sew repair of thoracoabdominal aortic aneurysms may effectively lower the incidence of spinal cord injury without prolonging aortic crossclamp time.     

Critical Analysis of Outcome Determinants Affecting Repair of Intact Aneurysms Involving the Visceral Aorta

Visceral (mesenteric and/or renal) ischemia/reperfusion phenomena likely contribute to the greater operative risk associated with pararenal and lower thoracoabdominal aortic aneurysm (TAA) repair. To differentiate the relative adverse effects of aortic clamp level, visceral ischemic duration, and various pre- and perioperative factors shared with infrarenal aneurysm patients, a comparative analysis of early and late outcomes after open repair of intact infrarenal and visceral aortic aneurysms was undertaken. A retrospective review of our university experience from 1993-1999/2002 revealed 549 patients (mean age 70 ± 8 years, 11% female) undergoing open repair of intact, degenerative aneurysms of the infrarenal (n = 391, 71%), juxtarenal (n = 78, 14%), suprarenal (n = 35, 7%), and type IV (n = 40, 7%) and type III (n = 5, 1%) TAA segments. All pararenal aneurysms required suprarenal (SR) or supravisceral (SV, above celiac or superior mesenteric artery) clamp placement. Concomitant renal reconstruction was done in 30% of visceral aortic and 3% of open infrarenal aneurysm repairs. Thirty-day adverse outcomes [death, renal failure (creatinine 2 × baseline or new dialysis), visceral (bowel, hepatic, renal, spinal cord, multiple organ dysfunction), and nonvisceral (cardiac, pulmonary, procedural) complications] were analyzed relative to patient and operative factors using univariate comparisons and multivariate stepwise logistic regression. Perioperative mortality rates varied significantly between aneurysm locations (infrarenal 2.1%, juxtarenal 2.6%, suprarenal 11.4%, TAA 13.3%; p < 0.01) and for clamp locations (infrarenal 2.1%, SR 3.0%, SV 10.8 %; p < 0.01) but were not different between juxtarenal (1.8% vs. 4.4 %) and SR (9.1% vs. 12.5%) aneurysms requiring SR or SV clamping, respectively. Visceral ischemic time (VIT) during SR or SV clamping, and not clamp location, was the only independent predictor of operative mortality [odds ratio (OR) = 10.8, 95% confidence interval (CI) 4-29]. Sensitivity analyses revealed VIT > 32 min to be the strongest predictor of early death. Visceral complication or renal failure affected 34% and 23% of visceral aortic (5% dialysis) and 7% and 5% (1% dialysis) of infrarenal repairs, respectively. VIT > 32 min, SV clamp placement, diabetes, and inflammatory aneurysm repair were each predictive of visceral complications and/or renal failure. Five-year survival rate was similar after visceral aortic (70%) and infrarenal (75%) repairs but negatively impacted only in patients with prior infrarenal abdominal aortic aneurysm repair and recurrent aneurysms (OR = 2.8, 95% CI 1.2-6.9). The high incidence of early adverse outcomes following repair of pararenal and lower thoracoabdominal aneurysms is primarily associated with excessive periods of renal and/or gut ischemia during visceral aortic clamp placement. However, nearly equivalent early and late survival was seen for visceral aortic and infrarenal repairs when VIT < 32 min was achieved.Presented at the Twenty-eighth Annual Meeting of the Southern Association for Vascular Surgery, Rio Grande, Puerto Rico, January 14-17, 2004.     

Role of the BioMedicus Pump and Distal Aortic Perfusion in Thoracoabdominal Aortic Aneurysm Repair

Abstract: We reviewed the role of the BioMedicus pump in the reduction of neurologic complications following the repair of Type 1 and Type 2 thoracoabdominal aortic aneurysms. Since 1991, we have used several different methods for the repair of thoracoabdominal aortic aneurysms including simple cross-clamping, selective use of the BioMedicus pump, cardiopulmonary bypass with or without profound hypothermia, and most recently, distal aortic perfusion using the BioMedicus pump combined with cerebral spinal fluid drainage. This latter method has been the most promising in rectifying the side effects of aortic clamping and in providing the time necessary for thorough thoracoabdominal aortic aneurysm repair. On our service, the ongoing study of the BioMedicus pump and distal aortic perfusion in conjunction with cerebral spinal fluid drainage has shown that these adjuncts can extend the tolerance of the spinal cord to ischemia and lower the overall rate of neurologic complications for Type 1 and Type 2 thoracoabdominal aortic aneurysm repairs to a rate of 5% (early results) and 3% (late results). We highly recommend distal aortic perfusion using the BioMedicus pump combined with cerebral spinal fluid drainage for thoracoabdominal aortic aneurysm repair.     

Collective experience with hybrid procedures for suprarenal and thoracoabdominal aneurysms

Not every patient is fit for open thoracoabdominal aortic aneurysm (TAAA) repair, nor is every TAAA or juxtarenal abdominal aortic aneurysm suitable for branched or fenestrated endovascular exclusion. The hybrid procedure consists of debranching of the renal and visceral arteries followed by endovascular exclusion of the aneurysm and might be an alternative in these patients. Between May 2004 and March 2006, 16 patients were treated with a hybrid procedure. The indications were recurrent suprarenal or thoracoabdominal aneurysms after previous abdominal and/or thoracic aortic surgery (n = 8), type I to III TAAAs (n = 3), proximal type I endoleak after endovascular repair (n = 2), penetrating ulcer of the juxtarenal aorta (n = 1), visceral patch aneurysm after type IV open repair (n = 1), and primary suprarenal aneurysm (n = 1). Eight (50%) of 16 patients were judged to be unfit for open TAAA repair. The hospital mortality rate was 31% (5 of 16). Four of five deceased patients were unfit for thoracophrenic laparotomy. Two patients died from cardiac complications and three from visceral ischemia. No spinal cord ischemia was detected, and temporary renal failure occurred in four patients (25%). The mean follow-up was 13 months (range 6-28 months). During follow-up, no additional grafts occluded and no patients died. Hybrid procedures are technically feasible but have substantial mortality (31%), especially in patients unfit for open repair (80%). They might be indicated when urgent TAAA surgery is required or when vascular anatomy is unfavorable for fenestrated endografts in patients with extensive previous open aortic surgery.     

Is organ ischaemia a determinant of the outcome of operations for suprarenal aortic aneurysms?

OBJECTIVE: To find out if morbidity and mortality after thoracoabdominal approaches for suprarenal aortic aneurysms are related to the duration of organ ischaemia. DESIGN: Retrospective study. SETTING: University hospital, The Netherlands. SUBJECTS: 72 operations for suprarenal aortic aneurysms. MAIN OUTCOME MEASURES: Duration of organ ischaemia, morbidity and mortality. RESULTS: There were 72 patients with 3 group A (Crawford type III), 10 group B (Crawford type IV), 37 group C (supracoeliac), and 22 group D (suprarenal) aneurysms. Median duration of ischaemia was 57 minutes for both the spinal cord and the mesenteric arteries, and 59 and 63 minutes for the right and left renal arteries, respectively. There were 52 major complications in 33 patients. Mesenteric ischaemia of longer than 60 minutes was associated with a significant higher complication rate (21/32, 66% compared with 13/40, 33%, p = 0.01). Spinal cord ischaemia of longer than 60 minutes was not associated with a significantly increased incidence of paraplegia (2/40 compared with 6/32, p = 0.13). CONCLUSIONS: We conclude that with surgery for suprarenal aneurysms a significant higher complication rate is noted with increased duration of mesenteric ischaemia.     

Impact of endovascular repair on open aortic aneurysm surgical training.

PURPOSE: The purpose of this study was to determine the impact of an endovascular stent-graft program on vascular training in open aortic aneurysm surgery. METHODS: The institutional and vascular surgery fellow experience in aortic aneurysm repair during a 6-year period was reviewed. The 3-year period before introduction of endovascular repair was compared with the 3-year period after introduction of endovascular repair. All patients undergoing abdominal aortic aneurysm (AAA) or thoracoabdominal aortic aneurysm repairs were entered prospectively into a vascular registry and retrospectively analyzed to evaluate the changing patterns in aortic aneurysm treatment and surgical training. RESULTS: Between July 1994 and June 2000, a total of 588 patients with AAA or thoracoabdominal aneurysms were treated at Stanford University Medical Center. There were 296 (50%) open infrarenal AAA repairs, 87 (15%) suprarenal AAA repairs, 47 (8%) thoracoabdominal aneurysm repairs, and 153 (26%) endovascular stent-grafts. The total number of aneurysms repaired per year by vascular fellows before the endovascular program was 71.3 +/- 4.9 (range, 68-77) and increased to 124.7 +/- 35.6 (range, 91-162) after introduction of endovascular repair (P <.05). This increase was primarily caused by the addition of endovascular stent-graft repairs by vascular fellows (51.0 +/- 29.0/year [range, 23-81]). There was no change in the number of open infrarenal aortic aneurysm repairs per year, 53.0 +/- 6.6 (range, 48-56) before endovascular repair versus 47.0 +/- 1.7 (range, 46-49) after (P = not significant). There was a significant increase in the number of suprarenal AAA repairs per year by vascular fellows, 10.0 +/- 1.0 (range, 9-11) before endovascular repair compared with 19.0 +/- 6.5 (range, 13-26) after (P <.05). There was no change in the number of thoracoabdominal aneurysm repairs per year between the two groups, 8.0 +/- 3.0 (range, 4-11) before endovascular repair compared with 7.6 +/- 2.3 (range, 5-9) after. CONCLUSIONS: Introduction of an endovascular aneurysm stent-graft program significantly increased the total number of aneurysms treated. Although the number of open aneurysm repairs has remained the same, the complexity of the open aneurysm experience has increased significantly for vascular fellows in training.     

Current strategies of spinal cord protection during thoracoabdominal aortic surgery

Despite improved survival rates after thoracoabdominal aortic aneurysm repairs, paraplegia remains a devastating complication with high incidence, ranging from 3 to 10%. Ischemic insults to the spinal cord are unavoidable during thoracoabdominal aortic aneurysm repairs. There is no single measure that can prevent paraplegia alone. A multimodality approach is required to minimize the ischemic insults during thoracoabdominal aortic aneurysm repairs and postoperative second hit to the spinal cord. Distal aortic perfusion is important to maintain the collateral network perfusion pressure, while cerebrospinal drainage allows to directly maintain the spinal cord perfusion. Reattachment of segmental arteries T8–T12 is encouraged to lower the incidence of both immediate and delayed paraplegia. Systemic arterial pressure should be maintained above 130 mmHg and cerebrospinal drainage should be continued until the second postoperative day, despite intact neurological status. In this article, we describe our current operative techniques and perioperative management in patients undergoing repairs of thoracoabdominal aortic aneurysm. A review of recent updates on spinal protection strategies is also reported.     

Type III and IV thoracoabdominal aortic aneurysm repair: results of a trifurcated/two-graft technique

OBJECTIVE: Thoracoabdominal aortic aneurysm (TAA) repair continues to present a surgical challenge because of obligate intraoperative visceral, renal, and spinal cord ischemia. A novel two-graft technique with a trifurcated graft for sequential visceral revascularization followed by a second graft for inline aneurysm reconstruction minimizes this endorgan ischemia. We herein present our updated experience with this approach for repair of type III and type IV TAAs. METHODS: Thirty-two patients (mean age, 70 years) underwent nonemergent repair of extent III (12 patients) and IV (20 patients) TAAs between March 1996 and October 2001. Repair was achieved with a trifurcated graft for uninvolved descending thoracic aorta-to-celiac/superior mesenteric/renal artery bypass with an additional tube or bifurcated graft for inline aneurysm reconstruction. Adjunctive cerebrospinal fluid drainage was used in the last six patients. Six patients had a solitary kidney, and six had previous infrarenal abdominal aortic aneurysm repair. RESULTS: Mean visceral ischemia times were as follows: celiac artery, 12 minutes; superior mesenteric artery, 12 minutes; left renal artery, 10 minutes; and right renal artery, 33 minutes. The creatinine level at discharge was not significantly different from the preoperative level (1.7 versus 1.3; P =.10). Two patients (6.3%) had transient renal failure; however, the permanent renal failure rate was zero. No patient with a solitary kidney had renal dysfunction develop. Paraplegia occurred in two patients (6.3%), one of whom had prior abdominal aortic aneurysm repair and neither of whom had cerebrospinal fluid drainage. Prolonged ventilatory support (>2 days) was necessitated in six patients (19%). The perioperative mortality rate was 6.3% (two patients). The mean follow-up period was 22 months, with a life-table survival rate of 76% at 36 months. Maintenance of preoperative functional status was achieved in 92% (23/25 patients) of long-term survivors. CONCLUSION: Type III and IVTAA repair with a trifurcated graft for sequential visceral revascularization followed by a second graft for inline aneurysm reconstruction provides short visceral, renal, and spinal cord ischemia times and leads to low rates of endorgan ischemic damage and paraplegia. Preoperative functional status is maintained in most survivors. These results compare favorably with other methods of TAA repair, and this technique presents a useful option in thoracoabdominal aortic reconstruction.     

Evaluation of spinal cord ischemia in endovascular stent graft repair and surgical operation of descending thoracic or thoracoabdominal aortic aneurysms

Between October 1996 and June 2003, endovascular stent graft repair was performed in 87 patients with descending thoracic aortic aneurysms, graft replacement was performed in 24 patients with thoracoabdominal aortic aneurysms, and endovascular stent graft repair with concomitant surgical bypass of abdominal visceral arteries was performed in 3 patients with thoracoabdominal aortic aneurysms. The retrievable stent graft was inserted and evoked spinal cord potential were monitored in order to predict spinal cord ischemia for stent graft repair. There was no paraplegia or hospital death, although 3 patients had paraparesis in stent graft repair. Two of the 3 patients with paraparesis made a full neurologic recovery. There were no cases of paraplegia or paraparesis in surgical operations with thoracoabdominal aortic aneurysm. The concomitant surgical procedure was a good technique for patients in whom cardiopulmonary bypass could not be used. Our results of stent graft repair and surgical operation for descending thoracic or thoracoabdominal aortic aneurysms were acceptable. The retrievable stent graft was useful for prediction of spinal cord ischemia before endovascular stent graft repair of descending thoracic or thoracoabdominal aortic aneurysm.     

Neurologic outcome after thoracic and thoracoabdominal aortic aneurysm repair

BACKGROUND: Neurologic deficit (paraparesis and paraplegia) after repair of the thoracic and thoracoabdominal aorta remains a devastating complication. The purpose of this study was to determine the effect of cerebrospinal fluid drainage and distal aortic perfusion upon neurologic outcome during repair of thoracic and thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: Between February 1991 and March 2000, we performed 654 repairs of the thoracic and thoracoabdominal aorta. The median age was 67 years and 420 (64%) patients were male. Forty-five cases (6.9%) were performed emergently. Distribution of TAAA was the following: extent I, 164 (25%); extent II, 165 (25%); extent III, 61 (9%); extent IV, 95 (15%); extent V, 23 (3.5%); and descending thoracic, 147 (22%). The adjuncts cerebrospinal fluid drainage and distal aortic perfusion were used in 428 cases (65%). RESULTS: Thirty-day mortality was 14% (94 of 654). The in-hospital mortality was 16% (106 of 654). Early neurologic deficits occurred in 33 patients (5.0%). Overall, 14 of 428 (3.3%) neurologic deficits were observed in the adjunct group, and 19 of 226 (8.4%) in the nonadjunct group (p = 0.004). When the adjuncts were used during extent II repair, the incidence was 10 of 129 (7.8%) compared with 11 of 36 (30.6%) in the nonadjunct group (p < 0.001). Multivariate analysis demonstrated that risk factors for neurologic deficit were cerebrovascular disease and extent of TAAA (II and III) (p < 0.05). CONCLUSIONS: The combined adjuncts of distal aortic perfusion and cerebrospinal fluid drainage demonstrated improved neurologic outcome with repair of thoracic and TAAAs. In extent II aneurysms, adjuncts continue to make a considerable difference in the outcome and to provide significant protection against spinal cord morbidity. Future research should focus on spinal cord protection in patients with high-risk extent II aneurysms.     

Delayed onset of neurologic deficit: significance and management

As contemporary adjuncts have substantially reduced the overall incidence of paraplegia and paraparesis after the surgical repair of thoracoabdominal aortic aneurysm, delayed-onset neurologic deficit has emerged as a significant clinical entity. It is generally agreed that neurologic deficits are attributable to the duration of spinal cord ischemia sustained during aortic cross-clamping. Factors known to increase the risk of spinal cord injury include the aneurysm extent, aortic cross-clamp time, aneurysm rupture, and associated acute aortic dissection. Clinically and experimentally, studies have shown different adjuncts to improve spinal cord protection, providing further insights into the pathophysiology of spinal cord ischemia. However, the pathophysiology of delayed-onset spinal cord deficit after thoracoabdominal aortic aneurysm repair remains largely controversial. This review discusses the significance and management of delayed-onset neurologic deficit.     

Combined endovascular and surgical approach (hybrid treatment) for management of type IV thoracoabdominal aneurysm

The purpose of this article is to report successful hybrid treatment of a sovraprosthetis type IV thoracoabdominal aneurysm. This technique was used in a 65-year-old man with chronic rupture of a type IV thoracoabdominal aneurysm not suitable for aortic cross-clamping because of a severe cardiopathy (left ventricular ejection fraction 20%); the patient underwent previous repairs of aortic arch and infrarenal abdominal aortic aneurysms. Perioperative complications were absent. Postoperative day 21 computed tomography and monthly duplex ultrasonography confirmed the complete exclusion of the aneurysm with proper perfusion of visceral vessels. At the seventh postoperative month, the patient died of a massive recurrence of myocardial infarction. Hybrid treatment for thoracoabdominal aneurysms may represent a valid solution for those patients with poor cardiac and respiratory reserve, reducing cardiac stress and the duration of visceral ischemia, which are still the main causes of morbidity and mortality for this type of intervention.     

The impact of walking impairment,cardiovascular risk factors,and comorbidity on quality of life in patients with intermittent claudication

PURPOSE: This study assessed the cardiovascular disease, perioperative results, and survival after surgical abdominal aortic aneurysm repair in young patients (< or = 50 years) compared with randomly selected older patients who also underwent abdominal aortic aneurysm repair. METHODS: We reviewed hospital records to identify young and randomly selected control patients (3 for each young patient, > or = 65 years, matched for year of operation) with degenerative (atherosclerotic) abdominal aortic aneurysms undergoing repair between Jan 1, 1988, and Mar 31, 2000. Patients with congenital aneurysms, pseudoaneurysms, aortic dissections, post-coarctation dilations, aortic infection, arteritis, or aneurysms isolated to the thoracic aorta were excluded. Mortality data and cause of death were obtained from medical records and the National Death Index RESULTS: Among 1168 patients who underwent abdominal aortic aneurysm repairs, 19 young patients (1.6%) and 57 control patients were identified. The mean age was 48.4 years in the young group and 72.2 years in the control group. There were no differences in sex or race between the two groups. When comparing existing cardiovascular disease between the groups, there were no differences in the incidence of earlier coronary revascularization (26% vs 16%) or non-cardiac vascular surgery (5% vs 9%), but aneurysms were more commonly symptomatic in young patients (53% vs 21%; P <.01). Aneurysmal disease was limited to the infrarenal aorta in similar proportions of patients (89% vs 88%). No statistically significant differences were seen in the incidence of perioperative deaths (16% young vs 9% control; P =.40) or postoperative complications (37% young vs 26% control; P =.38). The estimated survival rate of the young group was not different from that of the control group (3-year survival rate, 73% vs 69%; P =.32) or the entire cohort of patients (older than 50 years; n = 1101) who underwent repair of abdominal aortic aneurysms during the study period (3-year survival 73% vs 75%; P =.63) CONCLUSION: After abdominal aortic aneurysm repair, young patients had perioperative results and follow-up mortality rates similar to those of control patients. Cardiovascular disease was the predominant cause of death after abdominal aortic aneurysm repair in the young patients. When compared with an age older than 50 years at the time of abdominal aortic aneurysm repair, young age alone was not associated with increased survival.     

Motor and Somatosensory Evoked Potentials: Their Role in Predicting Spinal Cord Ischemia in Patients Undergoing Thoracoabdominal Aortic Aneurysm Repair with Regional Lumbar Epidural Cooling

Background: Paraplegia is a devastating complication for patients undergoing repair of thoracoabdominal aortic aneurysms. A monitor to detect spinal cord ischemia is necessary if anesthesiologists are to intervene to protect the spinal cord during aortic aneurysm clamping.

Methods: The medical records of 60 patients who underwent thoracoabdominal aortic aneurysm repair with regional lumbar epidural cooling with evoked potential monitoring were reviewed. The authors analyzed latency and amplitude of motor evoked potentials, somatosensory evoked potentials, and H reflexes before cooling and clamping, after cooling and before clamping, during clamping, and after release of aortic cross clamp.

Results: Twenty minutes after the aortic cross clamp was placed, motor evoked potentials had 88% sensitivity and 65% specificity in predicting spinal cord ischemia. The negative predictive value of motor evoked potentials at 20 min after aortic cross clamping was 96%.     

Epidural cooling for spinal cord protection during thoracoabdominal aneurysm repair: A five-year experience

PURPOSE: We developed and applied a method for providing regional spinal cord hypothermia with epidural cooling (EC) during thoracoabdominal aneurysm (TAA) repair. Preliminary results indicated significant reduction in spinal cord ischemic complications (SCI), compared with historical controls, and a 5-year experience with EC was reviewed. METHODS: From July 1993 to September 1998, 170 patients with thoracic aneurysms (n = 14; 8.2%) or TAAs (types I and II, n = 83 [49%]; type III, n = 66 [39%]; type IV, n = 7 [4.1%]) were treated with EC. An earlier aneurysm resection was noted in 44% of patients, an emergent operation was noted in 20% of patients, and an aortic dissection was noted in 16% of patients. The EC was successful (mean cerebrospinal fluid [CSF] temperature at cross-clamp, 26.4 +/- 3 degrees C) in 97% of cases, with all 170 patients included in an intention-to-treat analysis. The operation was performed with a clamp/sew technique (98% patients) and selective (T(9) to L(1) region) reimplantation of intercostal vessels. Clinical and EC variables were examined for association with operative mortality and SCI by means of the Fischer exact test, and those variables with a P value less than.1 were included in multivariate logistic regression analysis. RESULTS: The operative mortality rate was 9.5% and was weakly associated (P =.07) with SCI; postoperative cardiac complications (odds ratio [OR], 35. 3; 95% CI, 5.3 to 233; P <.001) and renal failure (OR, 32.2; 95% CI, 6.6 to 157; P <.001) were the only independent predictors of postoperative death. SCI of any severity occurred in 7% of cases (type I/II, 10 of 83 [12%]; all other types, 2 of 87 [2.3%]), versus a predicted (Acher model) incidence of 18.5% for this cohort (P =. 003). Half the deficits were minor, with good functional recovery, and devastating paraplegia occurred in three patients (2.0%). Independent correlates of SCI included types I and II TAA (OR, 8.0; 95% CI, 1.4 to 46.3; P =.021), nonelective operation (OR, 8.3, 95% CI, 1.8 to 37.7; P =.006), oversewn T(9) to L(2) intercostal vessels (OR, 6.1; 95% CI, 1.3 to 28.8; P =.023), and postoperative renal failure (OR, 23.6; 95% CI, 4.4 to 126; P <.001). These same clinical variables of nonelective operations (OR, 7.7; 95% CI, 1.4 to 41.4; P =.017), oversewn T(9) to L(2) intercostal arteries (OR, 9.7; 95% CI, 1.5 to 61.2; P =.016), and postoperative renal failure (OR, 20.8; 95% CI, 3.0 to 142.1; P =.002) were independent predictors of SCI in the subgroup analysis of high-risk patients, ie, patients with type I/II TAA. CONCLUSION: EC has been effective in reducing immediate, devastating, total paraplegia after TAA repair. A strategy that combines the neuroprotective effect of regional cord hypothermia, avoiding the sacrifice of potential spinal cord blood supply, and postoperative adjuncts (eg, avoidance of hypotension, CSF drainage) appears necessary to minimize SCI after TAA repair.     

Infected aortic aneurysms: clinical outcome and risk factor analysis

PURPOSE: Infected aortic aneurysms are difficult to treat, and are associated with significant mortality. Hospital survival is poor in patients with severe aortic infection, Salmonella species infection, Staphylococcus aureus infection, aneurysm rupture, and suprarenal aneurysm location. We reviewed the clinical outcome in 46 patients with primary infected aortic aneurysms and identified clinical variables associated with prognosis. METHODS: Data were collected by means of retrospective chart review. Univariate and multivariate logistic regression models were used for risk factor analysis. RESULTS: Between August 1995 and March 2003, 48 patients with primary infected aortic aneurysms were treated at our hospitals. Two patients with negative culture results were excluded. Of the remaining 46 patients, 35 patients had aortic aneurysms infected with Salmonella species and 11 patients had aortic aneurysms infected with microorganisms other than Salmonella species. There were 20 suprarenal infections and 26 infrarenal infections. Surgical debridement and in situ graft replacement were performed in 35 patients, with an early mortality rate of 11%. The incidence of late prosthetic graft infection was 10%. The 90-day mortality rate in patients operated on was 0% for elective operation and 36% for nonelective operation (P =.006, Fisher exact test). Independent predictors of aneurysm-related death were advanced age, non-Salmonella infection, and no operation. CONCLUSION: With timely surgical intervention and prolonged antibiotic treatment, in situ graft replacement provides an excellent outcome in patients with primary infected aortic aneurysms and elective operation. Mortality is still high in patients undergoing urgent operation. Advanced age, non-Salmonella infection, and no operation are major determinants of mortality.     

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.     

Spinal cord protection and operative results of the thoracoabdominal aortic aneurysm

The purpose of this study was to review retrospectively recent results in 75 patients undergoing thoracoabdominal aortic operations using the technique of distal aortic perfusion with segmental aortic clamping. Between July 1997 and November 2003, 46 males (61%) and 29 females (39%) were treated. The patients ranged in age from 26 to 82 (mean 63 +/- 13) years. Indications for surgery included dissecting thoracoabdominal aortic aneurysm (n = 28), atherosclerotic thoracoabdominal aortic aneurysm (n = 46), and traumatic aneurysm (n = 1). Emergency operation was performed in 8 (11%). The extent of aneurysm was Crawford type I in 12 patients, type II in 19, type III in 34, and type IV in 10. Profound hypothermic circulatory arrest was used in 3 patients and retrograde segmental clamping technique in 5. Cerebrospinal fluid drainage and naloxone hydrochloride administration were performed as adjunctive methods since February 2000. There were 6 (8%) in-hospital deaths. The overall incidence of postoperative paraplegia or paraparesis was 8% (6/75). Although the survival rate has improved, the problem of a complete prevention of ischemic spinal cord injury on the thoracoabdominal aortic operations remains unsolved. The multimodality approach is needed to reduce the risk of this devastating complication.     

Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial

OBJECTIVE: Despite the use of various strategies for the prevention of spinal cord ischemia, paraplegia and paraparesis continue to occur after thoracoabdominal aortic aneurysm (TAAA) repair. Although cerebrospinal fluid drainage (CSFD) is often used as an adjunct for spinal cord protection, its benefit remains unproven. The purpose of this randomized clinical trial was to evaluate the impact of CSFD on the incidence of spinal cord injury after extensive TAAA repair. METHODS: After randomization, 145 patients underwent extent I or II TAAA repairs with a consistent strategy of moderate heparinization, permissive mild hypothermia, left heart bypass, and reattachment of patent critical intercostal arteries. The repairs were performed with CSFD (n = 76) or without CSFD (n = 69). In the former group, CSFD was initiated during the operation and continued for 48 hours after surgery. The target CSF pressure was 10 mm Hg or less. RESULTS: The two groups had similar risk factors for paraplegia. Aortic clamp time, left heart bypass time, and number of reattached intercostal arteries were also similar in both groups. Thirty-day mortality rates were 5.3% (four patients) and 2.9% (two patients) for CSFD and control groups, respectively (P =.68). Nine patients (13.0%) in the control group had paraplegia or paraparesis develop. In contrast, only two patients in the CSFD group (2.6%) had deficits develop (P =.03). No patients with CSFD had immediate paraplegia. Overall, CSFD resulted in an 80% reduction in the relative risk of postoperative deficits. CONCLUSION: Perioperative CSFD reduces the rate of paraplegia after repair of extent I and II TAAAs.     

Endovascular repair of thoracoabdominal aortic aneurysms using fenestrated and branched endografts

Purpose

The study purpose was to review the outcomes of patients treated for thoracoabdominal aortic aneurysms using endovascular repair with fenestrated and branched stent-grafts in a single center.