Surgical Thoracoabdominal Aortic Aneurysm Repair in a Non-High-Volume Institution
01. Oktober 2019
14. Januar 2020
12. April 2020 (online)
Background Surgical thoracoabdominal aortic aneurysm (TAAA) repair remains challenging. Apart from mortality, spinal cord injury (SCI) is a dreaded complication. We analyzed our experience to identify predictors for SCI in a nonhigh-volume institution.
Patients and Methods All patients who underwent TAAA repair between February 1996 and November 2016 (n = 182) were enrolled. Most were male (n = 121; 66.4%), median age was 68 years (range: 21–84). Elective operations were performed in 153 instances (84.1%). Our approach to minimize SCI includes distal aortic perfusion, mild hypothermia, identification of the Adamkiewicz artery, and sequential aortic clamping. Cerebrospinal fluid drainage was introduced in 2001 and liberal use of selective visceral perfusion in 2006.
Results Early mortality was 12.1%; it was 8.5% after elective procedures. Reduced left ventricular function, nonelective setting, older age, and longer bypass time were identified as independent predictors for mortality in multivariable logistic regression model. Permanent SCI was observed in nine patients (4.9%), of whom seven (3.8%) developed paraplegia. In a multivariable logistic regression model for paraplegia, peripheral arterial disease (PAD), Crawford type II repair, smaller body surface area, and era before 2001 were identified as independent predictors, whereas only PAD was significant for SCI. The incidence of paraplegia was 13.8% in extensive repair out of the first 91 cases, whereas it was improved up to 2.7% thereafter.
Conclusion Using an integrated approach, acceptable outcome of TAAA repair can be achieved, even in a nonhigh-volume center. PAD and extensive involvement of the aorta are strong independent predictors for spinal cord deficit after TAAA repair.
All the authors have nothing to disclose with regard to commercial support.
- 1 Moulakakis KG, Karaolanis G, Antonopoulos CN. , et al. Open repair of thoracoabdominal aortic aneurysms in experienced centers. J Vasc Surg 2018; 68 (02) 634-645.e12
- 2 Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg 1993; 17 (02) 357-368 , discussion 368–370
- 3 Coselli JS, LeMaire SA, Preventza O. , et al. Outcomes of 3309 thoracoabdominal aortic aneurysm repairs. J Thorac Cardiovasc Surg 2016; 151 (05) 1323-1337
- 4 Crawford ES, Crawford JL, Safi HJ. , et al. Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients. J Vasc Surg 1986; 3 (03) 389-404
- 5 Hu Z, Li Y, Peng R. , et al. Multibranched stent-grafts for the treatment of thoracoabdominal aortic aneurysms: a systematic review and meta-analysis. J Endovasc Ther 2016; 23 (04) 626-633
- 6 Scali ST, Feezor RJ, Chang CK. , et al. Critical analysis of results after chimney endovascular aortic aneurysm repair raises cause for concern. J Vasc Surg 2014; 60 (04) 865-873 , discussion 873–875
- 7 Tanaka H, Ogino H, Minatoya K. , et al; Japanese Study of Spinal Cord Protection in Descending and Thoracoabdominal Aortic Repair investigators. The impact of preoperative identification of the Adamkiewicz artery on descending and thoracoabdominal aortic repair. J Thorac Cardiovasc Surg 2016; 151 (01) 122-128
- 8 Shiiya N, Kunihara T, Matsuzaki K, Yasuda K. Evolving strategy and results of spinal cord protection in type I and II thoracoabdominal aortic aneurysm repair. Ann Thorac Cardiovasc Surg 2005; 11 (03) 178-185
- 9 Coselli JS, LeMaire SA. Left heart bypass reduces paraplegia rates after thoracoabdominal aortic aneurysm repair. Ann Thorac Surg 1999; 67 (06) 1931-1934 , discussion 1953–1958
- 10 Safi HJ, Campbell MP, Miller III CC. , et al. Cerebral spinal fluid drainage and distal aortic perfusion decrease the incidence of neurological deficit: the results of 343 descending and thoracoabdominal aortic aneurysm repairs. Eur J Vasc Endovasc Surg 1997; 14 (02) 118-124
- 11 Etz CD, Kari FA, Mueller CS. , et al. The collateral network concept: a reassessment of the anatomy of spinal cord perfusion. J Thorac Cardiovasc Surg 2011; 141 (04) 1020-1028
- 12 Tanaka H, Minatoya K, Matsuda H. , et al. Embolism is emerging as a major cause of spinal cord injury after descending and thoracoabdominal aortic repair with a contemporary approach: magnetic resonance findings of spinal cord injury. Interact Cardiovasc Thorac Surg 2014; 19 (02) 205-210
- 13 Vacanti FX, Ames III A. Mild hypothermia and Mg++ protect against irreversible damage during CNS ischemia. Stroke 1984; 15 (04) 695-698
- 14 Strauch JT, Lauten A, Spielvogel D. , et al. Mild hypothermia protects the spinal cord from ischemic injury in a chronic porcine model. Eur J Cardiothorac Surg 2004; 25 (05) 708-715
- 15 Coselli JS, Bozinovski J, Cheung C. Hypothermic circulatory arrest: safety and efficacy in the operative treatment of descending and thoracoabdominal aortic aneurysms. Ann Thorac Surg 2008; 85 (03) 956-963 , discussion 964
- 16 Miyamoto K, Ueno A, Wada T, Kimoto S. A new and simple method of preventing spinal cord damage following temporary occlusion of the thoracic aorta by draining the cerebrospinal fluid. J Cardiovasc Surg (Torino) 1960; 1: 188-197
- 17 Coselli JS, LeMaire SA, Köksoy C, Schmittling ZC, Curling PE. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. J Vasc Surg 2002; 35 (04) 631-639
- 18 Cinà CS, Abouzahr L, Arena GO, Laganà A, Devereaux PJ, Farrokhyar F. Cerebrospinal fluid drainage to prevent paraplegia during thoracic and thoracoabdominal aortic aneurysm surgery: a systematic review and meta-analysis. J Vasc Surg 2004; 40 (01) 36-44
- 19 Kunihara T, Shiiya N, Yasuda K. Changes in S100β protein levels in cerebrospinal fluid after thoracoabdominal aortic operations. J Thorac Cardiovasc Surg 2001; 122: 1019-1020
- 20 Wynn MM, Mell MW, Tefera G, Hoch JR, Acher CW. Complications of spinal fluid drainage in thoracoabdominal aortic aneurysm repair: a report of 486 patients treated from 1987 to 2008. J Vasc Surg 2009; 49 (01) 29-34 , discussion 34–35
- 21 Conrad MF, Crawford RS, Davison JK, Cambria RP. Thoracoabdominal aneurysm repair: a 20-year perspective. Ann Thorac Surg 2007; 83 (02) S856-S861 , discussion S890–S892
- 22 Acher C. It is not just assisted circulation, hypothermic arrest, or clamp and sew. J Thorac Cardiovasc Surg 2010; 140 (6, Suppl): S136-S141 , discussion S142–S146
- 23 Schepens MA, Heijmen RH, Ranschaert W, Sonker U, Morshuis WJ. Thoracoabdominal aortic aneurysm repair: results of conventional open surgery. Eur J Vasc Endovasc Surg 2009; 37 (06) 640-645
- 24 Safi HJ, Estrera AL, Miller CC. , et al. Evolution of risk for neurologic deficit after descending and thoracoabdominal aortic repair. Ann Thorac Surg 2005; 80 (06) 2173-2179 , discussion 2179