Ourania Preventza

Outcomes of 3309 thoracoabdominal aortic aneurysm repairs

OBJECTIVE Since the pioneering era of E. Stanley Crawford, our multimodal strategy for thoracoabdominal aortic aneurysm repair has evolved. We describe our approximately 3-decade single-practice experience regarding 3309 thoracoabdominal aortic aneurysm repairs and identify predictors of early death and other adverse postoperative outcomes. METHODS We analyzed retrospective (1986-2006) and prospective data (2006-2014) obtained from patients (2043 male; median age, 67 [59-73] years) who underwent 914 Crawford extent I, 1066 extent II, 660 extent III, and 669 extent IV thoracoabdominal aortic aneurysm repairs, of which 723 (21.8%) were urgent or emergency. Repairs were performed to treat degenerative aneurysm (64.2%) or aortic dissection (35.8%). The outcomes examined included operative death (ie, 30-day or in-hospital death) and permanent stroke, paraplegia, paraparesis, and renal failure necessitating dialysis, as well as adverse event, a composite of these outcomes. RESULTS There were 249 operative deaths (7.5%). Permanent paraplegia and paraparesis occurred after 97 (2.9%) and 81 (2.4%) repairs, respectively. Of 189 patients (5.7%) with permanent renal failure, 107 died in the hospital. Permanent stroke was relatively uncommon (n = 74; 2.2%). The rate of the composite adverse event (n = 478; 14.4%) was highest after extent II repair (n = 203; 19.0%) and lowest after extent IV repair (n = 67; 10.2%; P < .0001). Estimated postoperative survival was 83.5% ± 0.7% at 1 year, 63.6% ± 0.9% at 5 years, 36.8% ± 1.0% at 10 years, and 18.3% ± 0.9% at 15 years. CONCLUSIONS Repairing thoracoabdominal aortic aneurysms poses substantial risks, particularly when the entire thoracoabdominal aorta (extent II) is replaced. Nonetheless, our data suggest that thoracoabdominal aortic aneurysm repair, when performed at an experienced center, can produce respectable outcomes.

Total arch replacement with frozen elephant trunk technique.

Our technique for replacing the aortic arch has evolved in recent years from femoral artery cannulation with retrograde cerebral perfusion and deep hypothermic circulatory arrest, to innominate artery cannulation as our first choice, combined with antegrade cerebral perfusion during systemic circulatory arrest with a nasopharyngeal temperature target of 24 °C, and a trifurcated Y-graft (1-3). We have recently reported in high-risk patients that endovascular technology facilitates the repair of arch aneurysms(4). With the help of endovascular stent grafts, we perform total arch replacement with a frozen elephant trunk (FET) in patients whose aneurysm extends through the upper or the entire descending thoracic aorta. If the aneurysm involves the aortic arch and the upper descending thoracic aorta, the repair is performed as a one-stage procedure with antegrade stent delivery of the endograft. If the aneurysm extends into the entire descending aorta, the repair is performed either in one stage with antegrade or retrograde delivery of the endograft or in two stages with retrograde delivery of the stent graft as the second stage of the repair. Our decision to proceed with one-stage versus two-stage repair is based on specific aortic arch anatomy, the complexity of the proximal repair, and the patient’s comorbidities.

Outcomes of open distal aortic aneurysm repair in patients with chronic DeBakey type I dissection

OBJECTIVES In patients with acute DeBakey type I dissection, endovascular repair of the descending thoracic aorta during proximal aortic repair is an increasingly popular approach to preventing distal aortic sequelae and subsequent repair. To better define the risks and outcomes associated with these secondary operations, we examined our contemporary experience with open distal aortic repair in patients with chronic type I aortic dissection. METHODS Data were collected between January 2005 and June 2013 regarding 198 consecutive open descending thoracic (n = 27) or thoracoabdominal (n = 171) aortic repairs performed in patients with chronic type I dissection. The median interval between the dissection onset and the subsequent distal operation was 5.0 years (interquartile range, 2.4-10.5 years). A total of 110 repairs (56%) were performed in patients with genetic disorders. RESULTS There were 14 early deaths (7%). Permanent paraplegia developed in 2 patients (1%), 5 patients (3%) had permanent stroke, and 9 patients (5%) had permanent renal failure. Factors associated with early death included greater age (P = .01), chronic obstructive pulmonary disease (P = .01), clamping proximal to the left subclavian artery (P = .004), and use of hypothermic circulatory arrest (P = .002). The use of cold renal perfusion (P < .001) was associated with early survival. Early death was not associated with genetic disorders, emergency surgery, or extent of aortic repair. There were 36 late deaths, yielding an actuarial 8-year survival of 65.6% ± 5.9%. At 7 years, freedom from repair failure was 95.7% ± 1.7%, and freedom from subsequent repair for disease progression was 84.8% ± 4.6%. CONCLUSIONS In survivors of DeBakey type I aortic dissection with distal aneurysm, open repair of the descending thoracic or thoracoabdominal aorta can be performed with excellent early survival, acceptable morbidity, and relatively few late aortic events.

Open repair of thoracoabdominal aortic aneurysms in experienced centers

Objective: We performed a systematic review and meta‐analysis aiming to assess the mortality and morbidity of all published case series on thoracoabdominal aortic aneurysms (TAAAs) in experienced centers treated with open repair. Methods: A systematic search of the literature published until April 2017 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. Separate meta‐analyses were conducted for overall in‐hospital mortality for TAAA, mortality according to the type of TAAA, spinal cord ischemia, paraplegia and paraparesis, cardiac events, stroke, acute kidney failure, and bowel ischemia. A metaregression analysis was performed with volume of the center, percentage of ruptured cases among the series, length of in‐hospital stay, and publication year as covariates. Results: A total of 30 articles were included in the meta‐analysis, corresponding to a total of 9963 patients who underwent open repair for TAAAs (543 ruptured). The pooled mortality rate among all studies was 11.26% (95% confidence interval [CI], 9.56‐13.09). Mortality was 6.97% (95% CI, 3.75‐10.90), 10.32% (95% CI, 7.39‐13.63), 8.02% (95% CI, 6.37‐9.81), and 7.20% (95% CI, 4.19‐10.84) for Crawford types I, II, III, and IV, respectively. Pooled spinal cord ischemia rate was estimated at 8.26% (95% CI, 6.95‐9.67), whereas paraparesis and paraplegia rates were 3.61% (95% CI, 2.25‐5.25) and 5% (95% CI, 4.36‐5.68), respectively. We estimated a pooled cardiac event rate of 4.41% (95% CI, 1.84‐7.95) and a stroke rate of 3.11% (95% CI, 2.36‐3.94), whereas the need for permanent dialysis rate was 7.92% (95% CI, 5.34‐10.92). Respiratory complications after surgery were as high as 23.01% (95% CI, 14.73‐32.49). Metaregression analysis evidenced a statistically significant inverse association between mortality and the volume of cases performed in the vascular center (t = −2.00; P = .005). Interestingly, a more recent year of study publication tended to be associated with decreased in‐hospital mortality (t = −1.35; P = .19). Conclusions: Our study showed that despite the advances in open surgical techniques, the morbidity and mortality of the technique continue to remain considerable. Despite the focus on mortality and spinal cord ischemia, respiratory complications, permanent postoperative renal dialysis, stroke rate, and cardiac events also affect the outcome. The estimated trend of lower mortality in high‐volume centers suggests that perhaps this type of service should be provided in a few reference centers that have an established record and experience in the management of these patients.

Redo Aortic Root Operations in Patients with Marfan Syndrome

Abstract Aortic root aneurysm is the most common cardiovascular manifestation requiring surgical intervention in patients with Marfan syndrome (MFS), a heritable thoracic aortic disease. Elective replacement of the aortic root is the treatment of choice for patients with aneurysmal complications of the aortic root and ascending aorta. There are two basic approaches to aortic root replacement: valve‐sparing (VS) and valve‐replacing (VR) techniques. After successful aortic root replacement surgery, several patients with MFS may develop a late complication related to their aortic disease process, such as developing a pseudoaneurysm of the coronary artery reattachment buttons, aneurysmal expansion, or aortic dissection in the remaining native aorta. These patients may also develop other late complications that are not specifically related to the heritable thoracic aortic disease, such as infections that can lead to dehiscence of some or all of the distal or proximal anastomosis. Because these complications are rare, the clinical volume of reoperations of the aortic root in patients with MFS is low, making it difficult to assess contemporary experiences with these procedures. Only a few published reports have examined reoperative aortic root surgery in patients with MFS, each of which had only a small series of patients. Herein, we describe our contemporary experience with reoperative aortic root replacement in patients with MFS and provide our operative approach for these uncommon procedures.

Variety is the spice of life: One-stage or two-stage repair of extensive chronic thoracic aortic dissection

From the Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI–Baylor St Luke’s Medical Center, Houston, Tex; and Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex. Disclosures: Dr Preventza participates in clinical trials for Vascutek Terumo and consults for and participates in clinical trials for Medtronic, Inc, and WL Gore & Associates. Dr Coselli consults for, receives royalties and a departmental educational grant from, and participates in clinical trials for Vascutek Terumo and consults for and participates in clinical trials for Medtronic, Inc, andWLGore & Associates. All other authors have nothing to disclose with regard to commercial support. Received for publication Nov 28, 2017; accepted for publication Dec 1, 2017; available ahead of print Jan 12, 2018. Address for reprints: Ourania Preventza, MD, One Baylor Plaza, BCM 390, Houston, TX 77030 (E-mail: opsmile01@aol.com). J Thorac Cardiovasc Surg 2018;155:1936-7 0022-5223/

Open aortic surgery after thoracic endovascular aortic repair

36.00 Copyright 2017 by The American Association for Thoracic Surgery https://doi.org/10.1016/j.jtcvs.2017.12.033 Preoperative computed tomography of dissecting arch and thoracoabdominal aorta aneurysm after acute type I aortic dissection repair.