Thoracoabdominal aneurysm repair: a 20-year perspective.
BACKGROUND
A variety of operative approaches and protective adjuncts have been used to minimize organ dysfunction and, in particular, spinal cord injury (SCI) after thoracoabdominal aneurysm (TAA) repair. There is no consensus with respect to the optimal approach.


METHODS
Reviewed were 445 consecutive TAA repairs done between January 1987 and December 2005. Clinical features included urgent operation in 103 patients (22.6%), of which 52 (11.4%) were ruptures. Operative management consisted of a clamp-and-sew technique with adjuncts in 417 patients (92%). Epidural cooling to prevent SCI was used in 240 (68%) extent I to III repairs. Predictors of mortality and SCI were assessed with multivariate analysis, and long-term survival was determined with Kaplan-Meier life-table analysis.


RESULTS
Operative mortality was 8.2% and was associated with preoperative serum creatinine level of 1.8 mg/dL or more (p = 0.005), intraoperative hypotension (p = 0.01), intraoperative transfusion requirement (p = 0.0008), postoperative SCI (p = 0.02), and postoperative renal failure (p < 0.0001). SCI of any severity occurred in 60 patients (13.2%), and 43 (9.5% of the total cohort) sustained major paraplegia. Epidural cooling significantly reduced the risk of SCI in patients with types I to III TAA (13.7% versus 29%, p = 0.01). Independent predictors of SCI included extent I/II aneurysms (p = 0.02), epidural cooling (p = 0.02), urgent/emergent operation (p = 0.02), intraoperative hypotension (p = 0.005), total aortic cross-clamp time (p = 0.01), and postoperative pulmonary complications (p = 0.003). Late survival rates were at 54.4% at 5 years, 28.7% at 10 years, and 20.5% at 15 years.


CONCLUSIONS
Despite the favorable impact of operative adjuncts on perioperative mortality and SCI, major morbidity after TAA remains a challenge; the implications to further develop stent graft strategies are clear.
Conrad
Mark F
MF
Division of Vascular and Endovascular Surgery, Harvard Medical School, Boston, Massachusetts, USA. mconrad@partners.org
Crawford
Robert S
RS
Davison
J Kenneth
JK
Cambria
Richard P
RP
D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000097:blood / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000097:blood / Q000601:surgery*; D001019:Aortic Rupture / Q000601:surgery; D001803:Blood Transfusion; D003404:Creatinine / Q000097:blood; D004824:Epidural Space; D005260:Female; D006801:Humans; D007022:Hypotension / Q000209:etiology; D007036:Hypothermia, Induced; D007431:Intraoperative Complications; D053208:Kaplan-Meier Estimate; D008171:Lung Diseases / Q000209:etiology; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010264:Paraplegia / Q000209:etiology; D011237:Predictive Value of Tests; D011446:Prospective Studies; D051437:Renal Insufficiency / Q000209:etiology; D013119:Spinal Cord Injuries / Q000209:etiology; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality
D003404:Creatinine