Open Repair of Ruptured Descending Thoracic and Thoracoabdominal Aortic Aneurysms in 100 Consecutive Cases Mario F. Gaudino, Christopher Lau, Monica Munjal,

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Presentation transcript:

Open Repair of Ruptured Descending Thoracic and Thoracoabdominal Aortic Aneurysms in 100 Consecutive Cases Mario F. Gaudino, Christopher Lau, Monica Munjal, Leonard N Girardi Department of Cardiothoracic Surgery Weill Cornell Medical College New York-Presbyterian Weill Cornell Medical College New York, NY I would like to thank Dr. Somberg and Dr. xxx for the invitation to speak at grand rounds today. Today’s topic focuses on the management of DTAs and TAAAs, two areas of the aorta where surgical repair has often been assoc with poor outcomes with high morbidity like paraplegia, renal failure and high mortality. I would like to take the next 45’ or so and show you how the repair of these has evolved and how high volume aneurysm centers can produce consistently good results while minimizing morb/mort. I will also take this opportunity to introduce to you some of the newer techniques used for repair, endovascular stent grafting and give you some idea how this compares to traditional repair.

Ruptured Series Demographics Ruptured versus Intact Series Demographics Ruptured Series Demographics Ruptured series Intact series p value (n=100) (n=575) Age (mean, std. dev.) 67.2 ± 14.3 64.3 ± 14.4 .06 Male 61 (61%) 336 (58.4%) .63 Smoking 94 (94%) 423 (73.6%) <.001 Previous coronary revascularization 20 (20%) 115 (20%) 1.0 Hypertension 97 (97%) 553 (96.2%) .686 Chronic pulmonary disease 60 (60%) 216 (37.6%) <.001 Previous stroke 8 (8%) 29 (5.1%) <.001 Peripheral vascular disease 38 (38%) 147 (25.6%) .01 Diabetes 17 (17%) 44 (7.7%) .003 Family history of aneurysm 1 (1%) 30 (5.2%) .06 Renal dysfunction 59 (59%) 147 (25.5%) <. 001 Previous cardiac surgery 38 (38%) 290 (50.4%) .09 Preoperative spinal cord injury 7 (7 %) 3 (0.5%) <. 001 Thoracoabdominal aortic aneurysm 57 (57%) 408 (70.9%) .05 Extent 1 and 2 48 (84.2%) 309 (75.7 %) . 06 Descending thoracic aneurysm 43 (43%) 167 (29.0%) .05 Aneurysm size (cm) (mean, std. dev.) 7.1 ± 2.0 6.9 ± 1.4 .140 Shock 27 (27%) 1 (0.2%) <.001 Emergent operation 96 (96%) 115 (20%) <.001 Data presented as n (%), unless otherwise noted.

Intraoperative Characteristics Ruptured series Intact series p value (n=100) (n=575) Clamp and sew 68 (68%) 370 (64.3%) .40 Circulatory arrest 11 (11%) 49 (8.5%) .42 Partial bypass 21 (21%) 205 (35.7%) . 15 Median partial bypass time (min) 32 28 .15 Median DHCA time (min) 31 33 .66 Median cross clamp time (min) 31 33 .35 Spinal drainage 65 (65%) 493 (85.7%) <.001 At least 1 intercostal reimplantation 22 (22%) 252 (43.8%) <.001 More than 1 intercostal reimplantation 11 (11%) 132 (22.9%) .001 Concomitant procedures 35 (35%) 173 (30.1%) <.001 Renal perfusion 15 (15%) 131 (22.8%) .21 Data presented as n (%), unless otherwise noted.

In-hospital Outcomes Ruptured series Intact series p value (n=100) Hospital and 30 day mortality 14 (14%) 24 (4.2%) .01 Myocardial infarction 7 (7%) 5 (0.8%) .004 Stroke 1 5 (0.8%) .86 Respiratory failure 19 (19%) 33 (5.7%) <.001 New dialysis 11 (11%) 24 (4.2%) .01 Spinal cord injury 5 (5%) 14 (2.4%) .16 Recurrent nerve lesion 9 (9%) 38 (6.6%) .38 Re-exploration for bleeding 2 (2%) 14 (2.4%) .79 Data presented as n (%), unless otherwise noted.

Univariate analysis for early death (ruptured series) Dead (n=14) Alive (n=86) P value Male 7 (50) 54 (62.8) 0.363 Smoking 14 (100) 80 (93.0) 0.308 Previous coronary revascularization 3 (21.4) 17 (19.8) 0.885 Hypertension 83 (96.5) 0.478 Chronic pulmonary disease 12 (85.7) 48 (55.8) 0.034 Previous stroke 5 (5.8) 0.046 Peripheral vascular disease 9 (64.3) 29 (33.7) 0.029 Diabetes 7 (50.0) 10 (11.6) <0.001 Family history of aneurysm 0 (0.0) 1 (1.2) 0.685 Renal dysfunction 12 (85.8) 47 (54.7) 0.028 Previous cardiac surgery 6 (42.9) 32 (37.2) 0.686 Preoperative spinal cord injury 4 (4.7) 0.023 Thoracoabdominal aneurysm 8 (57.1) 49 (57.0) 0.991 Extent 1 and 2 6 (75.0) 42 (48.8) 0.678 Shock 19 (22.1) 0.006 Emergent operation 82 (95.3) 0.410 Data presented as n (%), unless otherwise noted.

Preoperative Characteristics in Propensity-Matched Series Ruptured series (n=61) Intact series p value Age (mean, std. dev.) 66.8±14.0 65.6±12.4 .62 Male 35 (57.4) 33 (54.1) .85 Smoking 56 (91.8) 57 (93.4) .72 Previous coronary revascularization 11 (18.0) 9 (14.8) Hypertension 58 (95.1) 61 (100.0) .07 Chronic pulmonary disease 37 (60.7) NS Previous stroke 3 (4.9) .70 Peripheral vascular disease 18 (29.5) 16 (26.2) .68 Diabetes 8 (13.1) .79 Family history of aneurysm 1 (1.6) Renal dysfunction 26 (42.5) 29 (47.5) .95 Previous cardiac surgery 20 (32.8) .41 Preoperative spinal cord injury 4 (6.6) .17 Extent 1 and 2 30 (49.2) 32 (52.5) .89 Aneurysm size (mm) (mean, std. dev.) 7.2±2.1 7.2±2.0 .87 Emergent operation Data presented as n (%), unless otherwise noted.

In-hospital Outcomes in Propensity-Matched Series Ruptured series (n=61) Intact series p value In-hospital death 0 (0) 1 (1.6) 0.31 Myocardial infarction 2 (3.3) 0.15 Stroke 0.60 Respiratory failure 12 (19.7) 9 (14.8) 0.36 New dialysis 4 (6.6) 6 (9.8) 0.30 Spinal cord injury 4 (6.5) 0.35 Data presented as n (%), unless otherwise noted.

Conclusions Open repair of ruptured thoracic aortic aneurysms can be performed with a gratifying rate of salvage. The incidence of respiratory failure, renal failure and myocardial infarction are significantly higher than in patients with intact aneurysm. For patients with similar preoperative comorbidities, perioperative and long-term survival are not affected by the presence of a ruptured aneurysm. Experienced centers may be able to provide the advantage of reduced perioperative mortality and enhanced long-term survival.