Surgical treatment of thoracoabdominal aortic aneurysms by simple crossclamping: Risk factors and late results

Abstract

Between 1981 and 1987, 88 consecutive patients were operated on for a thoracoabdominal aortic aneurysm by simple crossclamping and a graft inclusion technique (without shunts or heparin). This article presents an analysis of the operative outcome and long-term foUow-up. Patient-and operationrelated variables are age (mean 64.3 years, range 28 to 82 years), sex (82 % men), rupture (20.5%), diabetes (2.3%~renal insufficiency (34.1%~chronic obstructive pulmonary disease (27.3%~previous aortic operation (31.8%), arterial hypertension (66%~postdissection (18.2%) versus degenerative (80.7%) origin, preoperative shock (11.4%~ischemic cerebrovascular (12.5%) or ischemic heart (17%) disease, peripheral vascular disease (14.8%), renal (mean 48 minutes, range 0 to 83 minutes) and lower spinal cord (mean 21 minutes, range 0 to 68 minutes) ischemic time, number of reattached intercostals, blood loss, and extent of the aneurysm (Crawford classification: type I, 16 patients [18.2%]; type II, 21 patients [23.8%]; type III, 29 patients [33%]; and type IV, 22 patients [25%]. Intraoperative mortality is 1.1% (n = 1). Thirty-day mortality is 5.9% (n = 5). Hospital mortality is 11.4% (n = 10): 7% for elective cases and 28 % for ruptured aneurysms (p =0.014). The survival at 2 years is 78 % ± (4.4%) and at 5 years 54 % ± (5.3%). Postoperative spinal cord injury occurred in 12 patients (13.8%) (5 had paraplegia and 7 had paraparesis) and postoperative renal dysfunction necessitating dialysis in 12 patients (14.1%). Risk stratification for hospital death, late death, renal failure, and spinal cord dysfunction was performed by means of multivariate logistic regression and Cox proportional hazard regression as appropriate. The best fitting.model to predict hospital death includes preoperative shock (p = 0.02~female sex (p = 0.06~preoperative elevated serum creatinine level (p = 0.06~and preoperative myocardial infarction (p = 0.08). Variables predictive for late death are postoperative dialysis (p = 0.002~age (p = 0.008~and rupture (p = 0.04). The risk factors of postoperative dialysis are age (p = 0.003) and preoperative serum creatinine level (p = 0.04). The risk of postoperative spinal cord dysfunction increases with longer lower spinal cord ischemic time (p =0.02) and with the presence of preoperative shock (p = 0.06).

Endovascular Grafting of the Thoracic Aorta, an Evolving Therapy: Ten‐year Experience in a Single Centre

“…This is partly because of the high morbidity associated with open repair, which is further compounded by the advancing age of this patient group the number of comorbid conditions and the extent of repair. 8,9,[12][13][14] Other reasons for the shift to endovascular grafting are the perceived benefits to both the patient and the utilization of hospital resources. Because of the less invasive nature of the procedure it is thought that there is a reduction in postoperative pain, blood loss, respiratory complications and use of intensive care facilities.…”

“…No patients undergoing elective endografting died within the first 30 days and this is similar to other reported series of both endovascular and open repair of the descending thoracic aorta, where the reported mortality ranges from 0 to 9.5% [14][15][16][19][20][21][22][23] and 2-30%. 3,[5][6][7][8][9]24 Urgent operations were undertaken in patients who had ruptured, rapidly expanding or symptomatic aneurysms. The early mortality rate of 12.5% is similar to the rates reported in other series of up to 38%.…”

“…Paraplegia results because of a disturbance of spinal cord blood supply. The reported incidence is 0-9% 14,15,22,[30][31][32][33] for endovascular and 0-13.8% 3,6,7,9,34,35 for open thoracic aneurysm repairs. Endovascular repair has the benefit of not requiring a period of aortic cross-clamping, with the associated haemodynamic shifts and spinal cord ischaemia.…”

“…Reported mortality for elective open replacement of the descending thoracic aorta varies between 2 and 30% with a high rate of associated morbidity, which increases with advanced age and number of comorbid conditions. [3][4][5][6][7][8][9] Overall 5-year survival for patients treated with open surgery varies between 25 and 60%.…”

Further Experience with Exsanguination for Descending Thoracic Aneurysms

“…This difference was not statistically significant. The nonsurvivors had fairly extensive aneurysms involving the thoracoabdominal aorta (5), the entire descending thoracic aorta (2), and the proximal descending thoracic aorta (1 ). Three had aortic dissection.…”