title: Evolution of operative strategies in open thoracoabdominal aneurysm repair.
abstract: OBJECTIVE
  During a 24-year interval, we managed >90% of thoracoabdominal aortic aneurysm (TAA) repairs with a clamp-and-sew (clamp/sew) approach supplemented with protective adjuncts, including renal hypothermia and epidural cooling with aggressive intercostal reconstruction for spinal cord protection. A finite paraplegia rate led to operative modifications using distal aortic perfusion (DAP) through atriofemoral bypass to support cord collateral circulation and selective intercostal reconstruction based on motor evoked potential (MEP) monitoring. This study evaluated the effect of DAP/MEP on perioperative outcomes.
  
  
  METHODS
  Consecutive patients undergoing repair of nonruptured Crawford extent I-III TAA using DAP/MEP were compared with propensity-matched patients treated with the clamp/sew technique. Outcomes included 30-day mortality and paraplegia.
  
  
  RESULTS
  There were 52 patients in the DAP cohort vs 127 undergoing clamp/sew. The DAP and clamp/sew cohorts differed in age (62.6 vs 69.5 years, P = .0003), presence of Marfan disease (10% vs 2%, P = .01), and chronic dissection (37% vs 8%, P = .001). Operative mortality was low (DAP, 2%; clamp/sew, 5%; P = .38). Postoperative renal insufficiency, although doubled in clamp/sew (17%) vs DAP (8%; P = .10), was not significant. DAP patients had a significantly lower incidence of intercostal reconstruction than the clamp/sew group (10% vs 34%, P < .0001), yet there was no paraplegia in the DAP cohort vs 5% in clamp/sew (P = .11). The composite death/paraplegia rate was decreased with DAP at 1 of 52 (2%) vs clamp/sew at 11 of 127 (9%; P = .01). Paraparesis with complete recovery occurred in 5 of 52 (10%) of the DAP group.
  
  
  CONCLUSIONS
  Elective TAA repair was accomplished with a low mortality in the DAP and clamp/sew cohorts. The use of MEP in the DAP cohort (despite a higher spinal cord ischemic risk due to the number of chronic dissection patients) decreased the need for intercostal reconstruction, with no paraplegia to date. DAP with MEP is the preferred operative strategy for extent I to III TAA repair.
authors.affiliation: Division of Vascular and Endovascular Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA. mconrad@partners.org
authors.forename: Mark F
authors.initials: MF
authors.lastname: Conrad
authors.forename: Emel A
authors.initials: EA
authors.lastname: Ergul
authors.forename: Virendra I
authors.initials: VI
authors.lastname: Patel
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Cambria
authors.forename: Glenn M
authors.initials: GM
authors.lastname: Lamuraglia
authors.forename: Mirela
authors.initials: M
authors.lastname: Simon
authors.forename: Richard P
authors.initials: RP
authors.lastname: Cambria
mesh_terms: D000368:Aged; D017545:Aortic Aneurysm, Thoracic / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001900:Boston; D016009:Chi-Square Distribution; D003097:Collateral Circulation; D003250:Constriction; D019054:Evoked Potentials, Motor; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods; D020335:Paraparesis / Q000209:etiology / Q000517:prevention & control; D010264:Paraplegia / Q000209:etiology / Q000517:prevention & control; D010477:Perfusion; D051437:Renal Insufficiency / Q000209:etiology / Q000517:prevention & control; D018570:Risk Assessment; D012307:Risk Factors; D020760:Spinal Cord Ischemia / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D013536:Suture Techniques; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality