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Independent associations with early mortality after open repair of Crawford extent IV thoracoabdominal aortic aneurysms

Read at the 102nd Annual Meeting of The American Association for Thoracic Surgery, Boston, Massachusetts, May 14-17, 2022.
https://doi.org/10.1016/j.jtcvs.2023.03.008Get rights and content

Abstract

Objective

We aimed to identify outcomes and factors that independently associate with early mortality after open repair of Crawford extent IV thoracoabdominal aortic aneurysms, defined as aneurysms confined to the segment below the diaphragm.

Methods

This retrospective analysis included 721 extent IV thoracoabdominal aortic aneurysm repairs performed in our institution from 1986 to 2021. Indications for repair were aneurysm without dissection in 627 cases (87.0%) and aortic dissection in 94 cases (13.0%). Overall, 466 patients (64.6%) were symptomatic preoperatively; 124 (17.2%) procedures were performed in patients with acute presentation, including 58 (8.0%) ruptured aneurysms.

Results

Operative death occurred after 49 (6.8%) repairs. Persistent renal failure necessitating dialysis occurred after 43 (6.0%) repairs. Binary logistic regression modeling revealed that previous extent II thoracoabdominal aortic aneurysm repair, chronic kidney disease, previous myocardial infarction, urgent or emergency repair, and longer crossclamp times during surgery were independently associated with operative mortality. Among early survivors (n = 672), competing risk analysis revealed that cumulative incidence of mortality and reintervention rates at 10 years were 74.8% (95% confidence interval, 71.4%-78.5%) and 3.3% (95% confidence interval, 2.2%-5.1%), respectively.

Conclusions

Although patient comorbidities contributed to operative mortality, factors associated with the repair, such as urgent or emergency status, the duration of aortic crossclamping, and certain types of complex reoperation, also played prominent roles. Patients who survive the operation can expect a durable repair that usually is free from late reintervention. Expanding our collective knowledge regarding patients who undergo open repair of extent IV thoracoabdominal aortic aneurysms will enable clinicians to establish best practices and improve patient outcomes.

Section snippets

Study Enrollment and Patient Characteristics

This was a study of consecutive extent IV TAAA repairs performed on our service from 1986 to 2021. Baylor College of Medicine's Institutional Review Board approved our clinical research protocol (#18095) in February 2006. Before this date, a waiver of consent was approved, and data were collected retrospectively from medical records. After this date, informed consent was obtained from patients or legally authorized representatives whenever possible; waivers of consent were approved for patients

Results

Between October 1986 and April 2021, our practice performed 3677 consecutive TAAA repairs, 721 of which were for an extent IV TAAA (Video Abstract). Of these 721 patients, 78 (10.8%) experienced an adverse event, including 49 (6.8%) operative deaths. We stratified our results by these events of interest.

Discussion

Crawford extent IV TAAA repair is associated with considerable risk for mortality and morbidity. In this study, 30-day mortality, operative mortality, and adverse event rates were 4.3% (n = 31), 6.8% (n = 49), and 10.8% (n = 78), respectively. Persistent stroke (n = 10, 1.4%) and persistent spinal cord deficit (n = 16, 2.2%) were infrequent events; however, persistent renal failure (n = 43, 6.0%) was a concern.

Comparisons with other contemporary series are hindered by the existence of few

Conclusions

Open repair of an extent IV TAAA is a formidable surgical procedure that poses significant risk. However, we have found that open repair of extent IV TAAAs that uses a predominantly clamp-and-sew technique and cold renal artery perfusion, along with a flexible patient-tailored approach to proximal and distal anastomoses and visceral or renal artery reattachment, is a durable procedure that can be performed with reasonable mortality and low rates of stroke and spinal cord deficit (Figure 4). The

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This work was not directly funded. Endowments from the Denton A. Cooley, MD, Chair in Cardiac Surgery (M.R.M.), the Jimmy and Roberta Howell Professorship in Cardiovascular Surgery at Baylor College of Medicine (S.A.L.), and the Cullen Foundation (J.S.C.) provided partial support to these faculty.

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