title: Predictors of early and late mortality following open extent IV thoracoabdominal aortic aneurysm repair in a large contemporary single-center experience.
abstract: OBJECTIVE
  The primary purpose of this study was to examine outcomes following open repair of extent IV thoracoabdominal aortic aneurysms (TAAAs) at a single university hospital. As a secondary aim, comparison was made to patients who underwent open abdominal aortic aneurysm (AAA) repair with supraceliac clamping but without left renal artery bypass to assess the effect of left renal artery bypass on outcomes.
  
  
  METHODS
  Patients undergoing open extent IV TAAA repair from 1998 to 2008 were identified (n = 108). Primary outcomes were 30-day and long-term survival. Secondary outcomes were major complication, renal failure, and postoperative change in renal function. A second analysis was performed, comparing patients undergoing extent IV TAAA repair with patients undergoing AAA repair with supraceliac clamping but without left renal artery bypass (n = 50).
  
  
  RESULTS
  Eighty-three men (76.9%) and 25 women (23.1%), with a mean age of 72.9 years, underwent open extent IV TAAA repair. Nine patients (8.3%) were ruptured. Mean aneurysm maximal diameter was 6.5 ± 1.3 cm. Supraceliac and left renal ischemic times were 22.9 ± 9.3 and 40.6 ± 16.2 minutes, respectively. Six patients (5.6%) died at 30 days. The only predictor of 30-day mortality was decreased preoperative estimated glomerular filtration rate (eGFR) (P = .044 by multivariate analysis; and P = .011 by univariate analysis). One-year and 5-year survival rates were 87% and 50%, respectively. Patients with a history of cerebrovascular disease (P = .001) and postoperative renal insufficiency (P = .034) had increased long-term mortality by log-rank test. Twenty-five (25.3%) patients sustained a postoperative decrease in renal function, while 19 (19.2%) patients had an improvement in renal function. There was no difference in 30-day mortality (5.6% vs 6.0%; P = 1.000), 5-year survival (50% vs 48%; P = .886), major complications (37.0% vs 38.0%; P = 1.000), renal failure (6.1% vs 0%; P = .215), or postoperative change in renal function, in patients undergoing extent IV TAAA repair vs AAA repair with supraceliac clamping but without left renal artery bypass.
  
  
  CONCLUSIONS
  Open extent IV TAAA repair can be performed with low morbidity and mortality rates. The performance of left renal artery bypass does not appear to contribute to the morbidity and mortality of extent IV TAAA repair. While decreased preoperative eGFR appears to increase the risk of 30-day mortality, a history of cerebrovascular disease and postoperative renal insufficiency appear to increase the risk of long-term mortality. Finally, open extent IV TAAA repair not uncommonly improves renal function.
authors.affiliation: Department of General Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa, USA.
authors.forename: Derek P
authors.initials: DP
authors.lastname: Nathan
authors.forename: Clayton J
authors.initials: CJ
authors.lastname: Brinster
authors.forename: Edward Y
authors.initials: EY
authors.lastname: Woo
authors.forename: Jeffrey P
authors.initials: JP
authors.lastname: Carpenter
authors.forename: Ronald M
authors.initials: RM
authors.lastname: Fairman
authors.forename: Benjamin M
authors.initials: BM
authors.lastname: Jackson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000401:mortality* / Q000503:physiopathology / Q000601:surgery*; D001027:Aortography / Q000379:methods; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality*; D002445:Celiac Artery / Q000601:surgery; D016009:Chi-Square Distribution; D003250:Constriction; D005260:Female; D005919:Glomerular Filtration Rate; D006785:Hospitals, University; D006801:Humans; D053208:Kaplan-Meier Estimate; D007668:Kidney / Q000503:physiopathology; D016015:Logistic Models; D008297:Male; D015143:Philadelphia; D016016:Proportional Hazards Models; D012077:Renal Artery / Q000601:surgery; D051437:Renal Insufficiency / Q000209:etiology / Q000503:physiopathology; D012092:Replantation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015996:Survival Rate; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome