Michael Corey

Functional outcome after thoracoabdominal aneurysm repair

OBJECTIVES Previous reports have documented perioperative outcomes and major complications (renal failure, spinal cord ischemia, death) after repair of aneurysms of the thoracoabdominal aorta (TAA). This study documented long-term functional outcomes after open TAA repair. METHODS The Medical Outcomes Study Short-Form 36-Item Survey (SF-36) was administered to 134 survivors (83 men, 51 women; mean age, 69.5 years) of TAA repair at a mean follow-up from surgery of 60 +/- 38.7 months. Raw scores were compared against cohorts adjusted for age and comorbidity (cardiovascular disease). Assessed was the influence of preoperative and intraoperative factors, as well as postoperative complications on long-term quality of life (QOL). RESULTS Raw scores for the eight SF-36 domains and the composite physical and mental component scores were lower (P < .01) in the TAA cohort compared with an age-adjusted reference population. Female gender and age >75 years decreased the physical functioning (P = .02) and role physical (P = .04) domains compared with male gender and patients <65 years old. Previously recognized systemic vascular disease lowered QOL in three SF-36 domains: general health (P = .013), social functioning (P = .003), and role emotional (P = .003); systemic vascular disease also showed a strong trend toward reduction in physical functioning (P = .09) compared with patients without systemic vascular disease. Neither TAA extent (I to IV) nor elective vs urgent/emergency operation influenced long-term QOL in our cohort. Patients with postoperative paraplegia, cerebrovascular accident/cardiac event, and those requiring reoperation showed lower scores in the physical functioning (P = .036), general health (P = .02), and Mental Health (P = .04) domains. Increased length of stay negatively impacted long-term QOL. The TAA cohort and the cardiovascular disease cohort had similar SF-36 scores for four domains (general health, bodily pain, vitality, and social functioning) and physical component scores. The cardiovascular disease group had higher scores in the physical functioning, role physical, role emotional, and mental health domains, and in mental component scores (P < .01). CONCLUSION Permanent loss of functional capacity, measured at a mean of 5 years postoperatively, occurs rarely in survivors of TAA repair. Further studies are needed to define the role of hybrid or endovascular strategies, including their impact on long-term functional outcome compared with open TAA repair.

Select early type IA endoleaks after endovascular aneurysm repair will resolve without secondary intervention

Objective Although it is traditionally considered ominous, the natural history of early proximal attachment site endoleaks (IA) after endovascular aneurysm repair (EVAR) is not well known. Our aim was to identify risk factors for persistent type IA endoleaks and to determine their effect on long‐term outcomes after EVAR. Methods All patients who underwent infrarenal EVAR at a single institution between 1998 and 2015 were identified. Preoperative axial imaging and intraoperative arteriograms were reviewed, and those patients with a type IA endoleak were further studied. Aneurysm features were characterized by two reviewers and were studied for predictors of persistent endoleaks at the conclusion of the case. Patient records and the Social Security Death Index were used to record 1‐year and overall survival. Results We identified 1484 EVARs, 122 (8%) of which were complicated by a type IA endoleak on arteriography after graft deployment, with a median follow‐up of 4 years. The majority of patients underwent additional ballooning of the proximal site (52 [43%]) or placement of an aortic cuff (47 [39%]); 30 patients (25%) received a Palmaz stent, and four patients were treated with coils or anchors. At case end, only 43 (35%) of the type IA endoleaks remained; at 1 month, only 16 endoleaks persisted (13%), and only six persisted at 1 year (6%). In multivariable analysis, the only independent predictor of persistence of type IA endoleak at the conclusion of the case was the presence of extensive neck calcifications (odds ratio [OR], 9.9; 95% confidence interval [CI], 1.4‐67.9; P = .02). Thirteen patients (11%) underwent reintervention for type IA endoleaks, with a time frame ranging from 3 days postoperatively to 11 years. There were three patients (2.4%) who experienced aneurysm rupture. Postoperative type IA endoleak was associated with lower survival at 1 year (79% vs 91%; relative risk, 2.5; 95% CI, 1.1‐5.4; P = .02), but it did not affect long‐term survival (log‐rank, P = .45). Both an increase in aneurysm sac size and failure of the endoleak to resolve by case end were independent predictors of a need for reintervention (growth: OR, 8.3; 95% CI, 2.2‐31.6; P < .01; persistent endoleak: OR, 7.6; 95% CI, 1.8‐31.5; P < .01). A persistent type IA endoleak was not independently associated with an increase in sac size on surveillance imaging (P = .28). Conclusions Aneurysm rupture secondary to persistent type IA endoleak is rare, and most will resolve within 1 year. Extensive neck calcification is the only independent predictor of persistent type IA endoleak, and an increase in sac size warrants reintervention. These data suggest that select early persistent type IA endoleaks can be safely observed.