1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

11. 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.