Harleen K. Sandhu

A Quarter Century of Organ Protection in Open Thoracoabdominal Repair.

INTRODUCTIONnThoracoabdominal aortic aneurysm (TAAA) remains a challenging problem. We sought to examine our experience with thoracic and thoracoabdominal aortic repairs over a 24-year period.nnnMETHODSnPatient information was collected in a prospective database and analyzed retrospectively. Univariate and multivariable analysis was performed.nnnRESULTSnBetween January 1991 and December 2014, we repaired 1896 descending thoracic (DTAA) or TAAA in 1795 patients. Mean age was 64.2u200a±u200a13.8, and 702 (37%) were women. Of 1896 operations, 646 (34.1%) were DTAA, 316 (16.7%) TAAA extent I, 310 (16.4%) TAAA extent II, 187 (9.9%) TAAA extent III, 348 (18.4%) TAAA extent IV, and 112 (5.9%) TAAA extent V. Adjunct [cerebrospinal fluid drainage (CSFD)u200a+u200adistal aortic perfusion (DAP)] was used in 78.4%. Mean preoperative glomerular filtration rate (GFR) was 75.1u200a±u200a14.9u200amL/min/1.73u200am. Renal dysfunction occurred in 461 (24.3%). Immediate neurodeficit (IND) occurred in 79 (4.2%) and delayed in 104 (5.5%). Of these, 47/104 (45%) recovered by discharge. Postoperative stroke was 95/1896 (5%). Early mortality was 302/1896 (15.9%). Mortality with GFR >95.3 was 28/457 (6.1%), and 131/432 (30.3%) was with GFRu200a<u200a48.3 (Pu200a<u200a0.0001). Predictors of early mortality were age (Pu200a<u200a0.02), GFR (Pu200a<u200a0.0001), TAAA2 or 3 (Pu200a=u200a0.001), coronary artery disease (Pu200a=u200a0.001), and emergency (Pu200a<u200a0.0001).nnnCONCLUSIONSnOpen DTAA and TAAA repair can be performed with acceptable early and late outcomes. This study provides important early- and long-term data on open repair, allowing for better risk stratification of patients with DTAA and TAAA. It is the high-risk subgroup that can now be targeted for endovascular techniques.

Open repair of chronic complicated type B aortic dissection using the open distal technique

AIMnThe present study aimed to analyze early and late outcomes after open repair of chronic type B aortic dissection.nnnMETHODSnWe retrospectively reviewed our cases of open descending thoracic aortic aneurysm (DTAA) with chronic dissection from 1991-2013. Long-term survival and aortic reinterventions were analyzed and patient comorbidities were evaluated in order to determine the risk of adverse outcomes. Furthermore, the technique for distal first approach is described.nnnRESULTSnBetween 1991 and 2013, 240 (40%) descending thoracic aortic repairs with associated chronic dissection were performed. Mean age is 59 years and 178 (74%) are men. The majority of patients (218, 91%) underwent repair using the adjunct of distal aortic perfusion with cerebral spinal fluid drainage. Early mortality was 8.3% (20/240). Permanent neurologic deficit occurred in 1.3% (3/240). Stroke occurred in 2.9% (7/240), and dialysis on discharge in 6% (12/240). 5-, 10-, 15-, and 20-year survival was 72%, 60%, 45%, and 39%, respectively. Freedom from reoperation on the operated segment was 97%, 94%, 94% and 94% at 5, 10, 15 and 20 years.nnnCONCLUSIONSnOpen repairs of chronic descending thoracic dissections can be performed with respectable morbidity and mortality. Risk of neurologic deficit remains low with use of adjuncts, and risk of reintervention on the involved aortic segment is also low. These results allow comparison with endovascular repair for chronic aortic dissection.

Repair of extensive aortic aneurysms: a single-center experience using the elephant trunk technique over 20 years.

Objectives:We report the early and late outcomes after repair of extensive aortic aneurysms using the 2-stage elephant trunk (ET) technique. Background:Management of aneurysm involving the entire aorta is a significant challenge. Given the anatomical complexity, the staged ET procedure was devised. A paucity of long-term data of outcomes of this approach exists. Methods:A single-center retrospective analysis of a prospectively collected database of all patients undergoing repair for extensive aortic aneurysm was performed. Results:Between 1991 and 2013, we repaired 3012 aneurysms of the ascending or thoracoabdominal aorta. Of these, we performed 503 operations in 348 patients using the ET technique. Mean age was 62.4 ± 14.3 years, and 156/346 (45.1%) operations were in women; 288 patients underwent first-stage ET with 157 receiving a complete second-stage repair. Index repair early mortality was 29/317 (9.1%). Completion stage early mortality was 17/186 = 9.1%. Stroke after first-stage ET repair was 10/297 (3.4%) and immediate neurologic deficit after the second-stage ET repair was 6/206 (2.9%). In the 131 patients who did not receive a second-stage repair, 17.8% died in the interval between 31 and 45 days. Conclusions:Extensive aortic aneurysm is a complex problem, but it can be managed safely with a 2-stage open procedure. Those patients who could not complete the completion repair fared poorly. Better predictors for early outcome need to be determined. The use of ET technique remains a valuable approach for repair of extensive aortic aneurysm.

Redo Thoracoabdominal Aortic Aneurysm Repair: A Single-Center Experience Over 25 Years

BACKGROUNDnAortic disease is a lifelong, progressive illness that may require repeated intervention over time. We reviewed our 25-year experience with open redo thoracoabdominal aortic aneurysm (TAAA) and descending thoracic aortic aneurysm (DTAA) repair. Our objectives were to determine patient outcomes after redo repair of DTAA/TAAA and compare them with nonredo repair. We also attempted to identify the risk factors for poor outcome.nnnMETHODSnWe reviewed all open redo TAAA and DTAA repairs between 1991 and 2014. Patient characteristics, preoperative, intraoperative variables, and postoperative outcomes were gathered. Data were analyzed by contingency table and by multiple logistic regression.nnnRESULTSnWe performed 1,900 open DTAA/TAAA repairs, with 266 (14%) being redos. Redos were associated with younger age (62 ± 16.4 years vs 64.5 ± 13.4 years, p < 0.02). Reasons for redo DTAA/TAAA were extension of the disease (86.8%), intercostal patch expansion (6.8%), visceral patch expansion (10.9%), infection (4.5%), anastomotic pseudoaneurysm (8.3%), and previous endovascular aortic repair complications (6.4%). Extent IV TAAA was predominantly involved in redos (42.8% redo vs 14.6% nonredo, p < 0.0001). The early mortality rate was significantly higher in redo (61 of 266 [23%]). Long-term survival was significantly lower among redo compared with nonredo DTAA/TAAAs. A multivariable analysis using the significant risk factors for early death from the risk factors on univariate analysis found four preoperative variables were significant (age >70 years, glomerular filtration rate <48 mL/min per 1.73m2, extent III TAAA, and emergency presentation) for predicting early death. In the presence of all four risk factors in a redo patient, a maximal risk of 82% for early death was predicted.nnnCONCLUSIONSnThe need for a redo operation in DTAA/TAAA repair is common and most often presents as an extension of the disease into an adjacent segment. A hybrid or completely endovascular treatment should be considered in high-risk patients.

Fluctuations in Spinal Cord Perfusion Pressure: A Harbinger of Delayed Paraplegia After Thoracoabdominal Aortic Repair

Delayed paraplegia (DP) following thoracoabdominal or descending thoracic aortic (TAA/DTA) repair is a dreaded complication. We reviewed our experience with the management of DP using our previously described COPS protocol (blood-pressure stabilization, cerebrospinal-fluid (CSP) draining and O2-delivery). Complete documentation of hourly CSP pressures and detailed hemodynamic variables were available since 2000. A case-control design was used to analyze the extensive hourly data in the perioperative period. Data were analyzed by contingency-tables, t test, and regression analysis, as appropriate. Between 2000 and 2011, we performed 1059 TAA/DTA repairs. Of these, 47 (4.4%) had DP and 31 (2.9%) had immediate neurologic deficit. Postoperatively, renal replacement therapy and drain complications were significantly associated with DP. Variation in systolic blood pressure (SBP) was also highly predictive. Similarly, spinal-cord perfusion pressure (SCPP = SBP ? SP) showed increased risk with greater variability closer to event day (OR 1.3, P = 0.009). Fluctuation of more than 15 mmHg in SBP in a 24-hour period was associated with 3.2-fold increased odds of DP (P = 0.004). In all, 8/47 (17%) made a full recovery, whereas 19 (40%) had partial recovery by discharge. The 30-day mortality was 18/47 (38%) in DP and 7/55 (13%) in controls (P < 0.001). Long-term survival was significantly lower among DP cases (5-year survival of 28% vs. 75%, P < 0.001). DP occurs infrequently and is predictably associated with intraoperative loss of MEP, postoperative renal replacement therapy, drain complications and unstable systolic and spinal-cord perfusion pressures. Increased vigilance is recommended for patients who experience any of these events.

Outcomes and management of type A intramural hematoma

BACKGROUNDnInitial optimal management of acute type A aortic dissection (ATAAD) with intramural hematoma (ATAIMH) remains controversial, especially between centers in the Eastern vs. Western worlds. We examined the literature and our experience to report outcomes after repair of ATAIMH.nnnMETHODSnWe reviewed the hospital, follow-up clinic records and online mortality databases for all patients who presented to our center for open repair of ATAAD between 1999 and 2014. Preoperative characteristics, early and long-term outcomes were compared between classic ATAAD vs. ATAIMH. Survival was analyzed using Kaplan-Meier and log-rank statistics.nnnRESULTSnOf the 523 repaired ATAAD, 101 patients (19%) presented with IMH and 422 (81%) had classic dissection. ATAIMH were significantly older (64.8±12.9 vs. 56.8±14.6 years; P<0.001), more commonly females (39% vs. 26%; P=0.010), had poor baseline renal function (i.e., glomerular filtration rate) (P<0.017), more retrograde dissections (27% vs. 8.3%; P<0.001), and less distal malperfusion (5% vs. 15%; P<0.001). Age greater than 60 years, female sex, retrograde dissection, and Marfan syndrome were strongly correlated with ATAIMH. Time to repair for ATAIMH was longer (median, 55.3 vs. 9.8 hours; P<0.001) with one death in ATAIMH within three days of presentation (0.9% vs. 6%; P=0.040). In all, 30-day mortality in ATAIMH was not different from classic ATAAD (12% vs.16%; P=0.289). A significantly lower incidence of postoperative dialysis in ATAIMH was noted (10% vs. 19%; P=0.034). When adjusted for age and renal function, late survival was improved with IMH (P<0.039).nnnCONCLUSIONSnATAIMH continues to be associated with significant morbidity and mortality, comparable to classic aortic dissection. A multidisciplinary management approach involving aggressive medical management and risk stratification for timely surgical intervention, along with genetic profiling, is recommended for optimal care. Long-term monitoring is mandatory to assess compliance to medical therapy and recognition of evolving complications.

Need for Limb Revascularization in Patients with Acute Aortic Dissection is Associated with Mesenteric Ischemia

BACKGROUNDnAcute aortic dissection (AAD) can cause limb ischemia due to branch vessel occlusion. A minority of patients have persistent ischemia after central aortic repair and require peripheral arterial revascularization. We investigated whether the need for limb revascularization is associated with adverse outcomes.nnnMETHODSnWe reviewed our cases of AAD from 2000 to 2014 and identified patients with malperfusion syndromes (coronary, cerebral, spinal, visceral, renal, or peripheral ischemia). Patients with DeBakey I/II (Stanford type A) dissection had urgent open repair of the ascending aorta. Patients with DeBakey III (Stanford type B) dissection were initiated on anti-impulse medical therapy and had either open aortic repair or thoracic endovascular aortic repair for malperfusion syndromes. Patients with persistent lower limb ischemia after aortic repair usually had either extra-anatomic bypass grafting or iliac stenting. Some DeBakey III patients had peripheral revascularization without central aortic repair. We performed univariate and multivariate analysis to determine the effects of need for limb revascularization and clinical outcomes.nnnRESULTSnWe treated 1,015 AAD patients (501 [49.4%] DeBakey I/II and 514 [50.6%] DeBakey III) with a mean age of 59.7xa0±xa014.5xa0years (67.5% males). Aortic repair was performed in all DeBakey I/II patients and in 103 (20.0%) DeBakey III patients. Overall 30-day mortality was 11.3%. Lower limb ischemia was present in 104 (10.3%) patients and was more common in DeBakey I/II compared with DeBakey III dissections (65.4% vs. 34.6%; odds ratio [OR] 2.1, confidence interval [CI] 1.4-3.2; Pxa0=xa00.001). Among the 40 patients who required limb revascularization, there was no difference in need for revascularization between DeBakey I/II and III patients. Patients requiring limb revascularization were more likely to have mesenteric ischemia compared with the rest of the cohort in both DeBakey I/II (Pxa0=xa00.037) and DeBakey III dissections (Pxa0<xa00.001) with worse 10-year survival (21.9 % vs. 59.2%, Pxa0<xa00.001). When adjusted for other malperfusion syndromes, patients with limb revascularization had similar long-term survival compared to uncomplicated dissection patients (Pxa0=xa00.960).nnnCONCLUSIONSnPatients requiring lower limb revascularization after treatment for AAD are more likely to have mesenteric ischemia and worse survival. The need for limb revascularization is a marker for more extensive dissection and should prompt evaluation for visceral malperfusion.

Intercostal artery management in thoracoabdominal aortic surgery: To reattach or not to reattach?

Background: The need for intercostal artery (ICA) reattachment in surgery for descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) remains controversial. We reviewed our experience over a 14‐year period to assess the effects of ICA management on neurologic outcome after DTAA/TAAA repair. Methods: Intraoperative data were reviewed to ascertain the status of T3‐12 ICAs and L1‐4 ICAs. Arteries were classified as reattached, ligated, occluded, or not exposed. Temporality of reattachment or ligation in response to an intraoperative ischemic event (ie, loss of motor evoked potentials [MEPs]) was noted. Adjustment for other predictors of immediate or delayed paraplegia (DP) was performed by multiple logistic regression. The effects of specific artery level and type of reattachment technique were assessed using stratified contingency tables. Results: A total of 1096 DTAA/TAAAs were performed between 2001 and 2014. The mean patient age was 64 ± 15 years, and 37% were female. Spinal cord ischemia was identified in 10% of patients, including 35 (3%) immediate cases and 77 (7%) DP cases. Overall DP resolution was 47% at discharge. ICA ligation and intraoperative MEP changes were strong predictors of postoperative paraplegia. Multivariable analysis demonstrated that T8‐12 ICA ligation significantly increased the risk for paraplegia (odds ratio, 1.3/artery; P < .041) even after adjustment for age >65 years, glomerular filtration rate, extent of II/III aneurysm, increased operative time, and intraoperative MEP loss. Conclusions: Loss of intraoperative MEPs is serious, and increases the risk of paraplegia in any ICA management strategy. Even with intact MEP, ligation of T8‐12 ICAs is associated with increased risk. These findings support reattachment of T8‐12 ICAs whenever feasible.

Minimally Invasive Techniques for Total Aortic Arch Reconstruction

The cumulative experience with endovascular aortic repair in the descending thoracic and infrarenal aorta has led to increased interest in endovascular aortic arch reconstruction. Open total arch replacement is a robust operation that can be performed with excellent results. However, it requires cardiopulmonary bypass and circulatory arrest and, therefore, may not be tolerated by all patients. Minimally invasive techniques have been considered as an alternative and include hybrid arch debranching, parallel stent graft deployment in the chimney and snorkel configurations, and complete endovascular branched reconstruction with multi-branched devices. This review discusses the evolving use of endovascular techniques in the management of aortic arch pathology and considers their relevance in an era of safe and durable open aortic arch reconstruction.

Metabolic Syndrome but Not Obesity Adversely Affects Outcomes After Open Aortoiliac Bypass Surgery

BACKGROUNDnAlthough the incident risk of peripheral artery disease increases in patients with metabolic syndrome, several authors report favorable outcomes in obese patients after arterial bypass surgery. We examine the effect of the so-called obesity paradox and metabolic syndrome on outcomes after open aortoiliac bypass surgery.nnnMETHODSnWe identified patients between 2004 and 2015 who had open surgical bypass for aortoiliac occlusive disease. We excluded patients with endovascular repair and those treated primarily for aneurysmal disease. Variables that were analyzed included preoperative medical history, Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease II classification, Rutherford classification, intra-operative, and postoperative outcomes. Metabolic syndrome was defined by World Health Organization criteria: diabetes and 2 or more of dyslipidemia, hypertension, and obesity (body mass index > 30xa0kg/m2). Data were analyzed by stratified Kaplan-Meier and multiple Cox regression for outcomes including long-term mortality and reintervention rate.nnnRESULTSnThere were 154 open bypass surgery patients during the study period with a median age of 60xa0years (interquartile range [IQR] 53-68), median glomerular filtration rate 76.1xa0mL/min (IQR 54-102), and 58% female prevalence. In all, 53 patients had metabolic syndrome (4%), and 14 patients (9%) were obese but did not have metabolic syndrome. Primary bypass graft patency was 89.0xa0±xa02.7% at 1 year and 77.4xa0±xa04.1% at 5 years and was not significantly different between metabolic syndrome, obese, and nonmetabolic syndrome patients. Reintervention rate for the entire cohort was 25.3xa0±xa03.7% at 1 year and 40.6xa0±xa04.7% at 5 years. In those with and without metabolic syndrome, reintervention rate at 1 and 5 years was 33.0xa0±xa06.8% vs. 21.1xa0±xa04.2% and 56.1xa0±xa07.9% vs. 30.7xa0±xa05.4%, respectively (log-rank Pxa0=xa00.003). In multivariable analyses, metabolic syndrome (hazard ratio [HR] 1.8, Pxa0=xa00.036) and critical limb ischemia (CLI) (HR: 3.2, Pxa0=xa00.001) were the only independent predictors of reintervention. Neither obesity nor the individual components comprising metabolic syndrome was a risk for reintervention. Multivariate analysis demonstrated age, female gender, CLI, and nonobesity as the independent risk factors for long-term mortality.nnnCONCLUSIONSnOur study supports the obesity paradox that obesity by itself is not a risk factor for reintervention and was a protective factor for mortality after open aortoiliac bypass surgery. Bypass graft patency and major amputation rates were not affected. Although the individual components do not predispose to worse outcome, metabolic syndrome is a constellation of factors that, together, are associated with adverse events.