1. Outcomes of 3309 Thoracoabdominal Aortic Aneurysm Repairs
Joseph S. Coselli, M.D. ?
Scott A. LeMaire, MD
Ourania Preventza, MD
Kim I de la Cruz, MD
Denton A. Cooley, MD
Matt D. Price, MS
Alan Stolz, Med
Susan Y. Green, MPH
Courtney N. Arredondo, MSPH
Todd K. Rosengart, MD
95th Annual Meeting, American Association of Thoracic Surgery (AATS)
Plenary Scientific Session: Abstract 1
Seattle, Washington • Monday, April 27, 2015 1

2. Disclosure GlaxoSmithKline PI Clinical Trial Vascutek,
a Terumo company
Royalties
Consultant
Educational Grant
Medtronic, Inc
WL Gore & Associates

3. Thoracoabdominal Aortic Aneurysm
E. Stanley Crawford refined and standardized repair
Improved technique
Categorized by extent of repair
Greatest aortic surgeon of era
E. Stanley Crawford

4. Thoracoabdominal Aortic Aneurysm
E. Stanley Crawford refined and standardized repair
Improved technique
Categorized by extent of repair
Greatest aortic surgeon of era
Our practice built on his legacy
E. Stanley Crawford

6. 3309 TAAA Repairs October 1986 to December 2014
Study Enrollment
Clinical research protocol approved by Baylor College of Medicine in 2006
Prospective from 2006
Retrospective before 2006
Single-practice series
Baylor College of Medicine’s institutional review board approved our clinical research protocol in For patients who underwent surgery after protocol approval, data were collected prospectively, and informed consent was obtained whenever possible; waiver of consent was approved for patients who could not provide consent because of illness and whose family members were not available. For patients who underwent surgery before protocol approval, data were collected retrospectively from medical records, and consent was waived.
From October 1986 to December 2014, 3320 consecutive open TAAA repairs  were performed on our service; of these, 3309 repairs met criteria for inclusion in our clinical database and form the basis of this report. Repairs included 914 Crawford extent I TAAA  For our records, how many refused consent?
Per MP, From October 1986 to December 2014, 4 TAAA patients “refused consent.” We were unable to consent 7 others who remain “not approved” because they could not be consented during hospitalization or could not be contacted thereafter.

7. 914
1066
660
669

8. Patient Characteristics (n = 3309) n (%)
Thoracoabdominal
Aortic Aneurysm Repair
Patient Characteristics (n = 3309)
n (%)
Median age, y [IQR]; range 12 y to 92
67 [59-73]
Age ≤ 50 y
439 (13.3)
Age > 79 y
193 (5.8)

9. Patient Characteristics (n = 3309) n (%)
Thoracoabdominal
Aortic Aneurysm Repair
Patient Characteristics (n = 3309)
n (%)
Median age, y [IQR]; range 12 y to 92
67 [59-73]
Age ≤ 50 y
439 (13.3)
Age > 79 y
193 (5.8)
Aortic dissection involving distal aorta
1185 (35.1)
Acute or subacute dissection
165 (5.0)
Chronic dissection
1020 (30.8)

10. Patient Characteristics (n = 3309) n (%)
Thoracoabdominal
Aortic Aneurysm Repair
Patient Characteristics (n = 3309)
n (%)
Median age, y [IQR]; range 12 y to 92
67 [59-73]
Age ≤ 50 y
439 (13.3)
Age > 79 y
193 (5.8)
Aortic dissection involving distal aorta
1185 (35.1)
Acute or subacute dissection
165 (5.0)
Chronic dissection
1020 (30.8)
Connective tissue disorder
330 (10.0)
Marfan syndrome
288 (8.7)

11. 3309 TAAA Repairs Preoperative Characteristics by Extent of Repair
Age y [IQR]
Chronic
Dissection
n (%)
Connective
Tissue Disorder I
(n=914)
67 [57-73]
352 (38.5)
67 (7.3) II
(n=1066)
66 [56-72]
469 (44.0)
177 (16.6)
III
(n=660)
69 [61-74]
124 (18.8)
56 (8.5) IV
(n=669)
70 [64-75]
75 (11.2)
30 (4.5)
Total
67 [59-73]
1020 (30.8)
330 (10.0)
P=0.0001
P<0.001

12. Aortic Dissection by Type (%)

13. Aortic Aneurysm Repair Patient Characteristics (n = 3309) n (%)
Thoracoabdominal
Aortic Aneurysm Repair
Patient Characteristics (n = 3309)
n (%)
Hypertension
2805 (84.8)
Hyperlipidemia
967 (29.2)
Diabetes
261 (7.9)
Coronary artery disease
1232 (37.2)
Previous coronary artery bypass graft
496 (15.0)
Prior myocardial infarction
652 (19.7)

14. 3309 TAAA Repairs Coronary Artery Disease by Extent of Repair
Disease, n (%)
Previous CABG
n (%)
Previous MI I
(n=914)
259 (28.3)
98 (10.7)
131 (14.3) II
(n=1066)
351 (32.9)
136 (12.8)
181 (17.0)
III
(n=660)
291 (44.1)
121 (18.3)
162 (24.6) IV
(n=669)
331 (49.5)
141 (21.1)
178 (26.6)
Total
1232 (37.2)
496 (15.0)
652 (19.7)
P<0.001

15. 3309 TAAA Repairs Preoperative Characteristics by Extent of Repair
Chronic renal insufficiency
n (%)
Chronic renal failure I
(n=914)
15 (1.6)
11 (1.2) II
(n=1066)
28 (2.6)
17 (1.6)
III
(n=660)
30 (4.6)
18 (2.7) IV
(n=669)
26 (3.9)
14 (2.1)
Total
99 (3.0)
60 (1.8)
P=0.004
P=0.1

16. 3309 TAAA Repairs Preoperative Characteristics by Extent of Repair
Pulmonary disease
n (%)
COPD
Past /Current Tobacco I
(n=914)
314 (34.4)
288 (31.5)
669 (73.2) II
(n=1066)
363 (34.1)
334 (31.3)
835 (78.3)
III
(n=660)
322 (48.8)
303 (45.91)
546 (82.7) IV
(n=669)
299 (44.7)
289 (43.2)
566 (84.6)
Total
1298 (39.2)
1214 (36.7)
2616 (79.1)
P<0.001

17. 3309 TAAA Repairs Preoperative Symptoms by Extent of Repair
Asymptomatic
no. (%)
Symptomatic
Acute symptoms I
(n=914)
311 (34.0)
603 (66.0)
169 (18.5) II
(n=1066)
400 (37.5)
666 (62.5)
161 (15.1)
III
(n=660)
239 (36.2)
421 (63.8)
109 (16.5) IV
(n=669)
242 (36.2)
427 (63.8)
110 (16.4)
Total
1192 (36.0)
2117 (64.0)
549 (16.6)
P=0.5
P=0.3

18. 3309 TAAA Repairs Rupture and PVD by Extent of Repair
Peripheral Vascular
Disease I
(n=914)
48 (5.3)
148 (16.2) II
(n=1066)
32 (3.0)
252 (23.6)
III
(n=660)
43 (6.5)
191 (28.9) IV
(n=669)
47 (7.0)
264 (39.5)
Total
170 (5.1)
855 (25.8)
P<0.001

19. 3309 TAAA Repairs Prior Aortic Repair by Extent of Repair
Failure of Prior
Aortic Repair  I
(n=914)
145 (15.9)
9 (1.0) II
(n=1066)
198 (18.6)
23 (2.2)
III
(n=660)
276 (41.8)
47 (7.1) IV
(n=669)
244 (36.5)
57 (8.5)
Total
863 (26.1)
136 (4.1)
P<0.001

20. Intraoperative Strategies
All extents
Moderate heparinization
Permissive mild hypothermia
Aggressive reattachment of segmental arteries
Cold renal perfusion whenever renal ostia can be accessed
Expeditious repair
Extent I and II repairs
Cerebrospinal fluid drainage
Left heart bypass
Selective celiac/SMA perfusion

21. 3309 TAAA Repairs Urgency of Repair by Extent of Repair
Elective
n (%)
Urgent
Emergent I
(n=914)
700 (76.6)
131 (14.3)
83 (9.1) II
(n=1066)
866 (81.2)
127 (11.9)
73 (6.8)
III
(n=660)
504 (76.4)
86 (13.0)
70 (10.6) IV
(n=669)
516 (77.1)
84 (12.6)
69 (10.3)
Total
2586 (78.2)
428 (12.9)
295 (8.9)
P=0.03
P=0.4
P=0.02

22. Aortic Aneurysm Repair Operative Details (n = 3309) n (%)
Thoracoabdominal
Aortic Aneurysm Repair
Operative Details (n = 3309)
n (%)
Redo thoracotomy
563 (17.0)
Extraction of endograft
48 (1.5)
Extraction of TEVAR
29 (0.7)
Reverse elephant trunk
80 (2.4)
Completion of elephant trunk
133 (4.0)
Clamping proximal to the
left subclavian artery (LSCA)
517 (15.6)

23. 3309 TAAA Repairs Aortic Clamp and Ischemic Times by Extent of Repair
Aortic Clamp Time
min, med [IQR]
Intercostal Total Time min, med [IQR]
Intercostal Unprotected Time min, med [IQR] I
(n=914)
40.5 [32-52]
40.0 [31-50]
26.0 [20-32] II
(n=1066)
63.0 [53-75]
52.0 [ ]
35.0 [27-42]
III
(n=660)
43.0 [34-53]
35.0 [27-44]
33.5 [26-42] IV
(n=669)
41.0 [ ]
31.0 [24-40]
Total
48.0 [36-62]
40.0 [30-52]
31.0 [24-39]
P<.001

24. 3309 TAAA Repairs Operative Details by Extent of Repair
Intercostal/Lumbar
Artery Reattachment
n (%) I
(n=914)
498 (54.5) II
(n=1066)
941 (88.3)
III
(n=660)
221 (33.5) IV
(n=669)
15 (2.2)
Total
1675 (50.6)
P<.001

25. 3309 TAAA Repairs Management of Visceral Arteries by Extent of Repair
Visceral/Renal Endarterectomy
n (%)
Visceral/Renal Stent
or Stent
Visceral/Renal Endarterectomy or Stent or Bypass I
(n=914)
51 (5.6)
15 (1.6)
58 (6.3)
88 (9.6) II
(n=1066)
275 (25.8)
86 (8.1)
303 (28.4)
510 (47.8)
III
(n=660)
250 (37.9)
73 (11.1)
270 (40.9)
357 (54.1) IV
(n=669)
281 (42.0)
90 (13.5)
405 (60.5)
Total
857 (25.9)
264 (8.0)
940 (28.4)
1360 (41.1)
P<0.001

26. 3309 TAAA Repairs Perfusion by Extent of Repair
Left Heart Bypass
n (%)
Selective Celiac/Superior Mesenteric I
(n=914)
557 (60.9)
60 (6.6) II
(n=1066)
874 (82.0)
675 (63.3)
III
(n=660)
43 (6.5)
36 (5.5) IV
(n=669)
6 (0.9)
8 (1.2)
Total
1480 (44.7)
779 (23.5)
P<.001

27. 3309 TAAA Repairs Operative Details by Extent of Repair
Cold Renal Perfusion
n (%) I
(n=914)
158 (17.3) II
(n=1066)
701 (65.8)
III
(n=660)
511 (77.4) IV
(n=669)
564 (84.3)
Total
1934 (58.4)
P<.001

28. Operative Mortality The most inclusive category of early death:
In-hospital death regardless of the length of hospital stay
In-hospital death includes any death after transfer to another hospital or long term acute care facility
30-day death, including those rare deaths after discharge to home

29. Adverse Event A composite endpoint Comprised of: Operative mortality
Permanent stroke
Permanent paraplegia
Permanent paraparesis
Permanent renal failure
30-day or in-hospital death, including death after transfer
Permanent = present at time of hospital discharge or early death

30. Life-Altering Complication
Discharge of early survivors with a complication that negatively impacts quality of life and longevity
Discharge with unresolved:
Paraplegia
Paraparesis
Stroke
Renal failure necessitating dialysis

31. 3309 TAAA Repairs Early Outcomes by Extent of Repair
Adverse Event
n (%)
Operative Death
30-Day I
(n=914)
98 (10.7)
54 (5.9)
34 (3.7) II
(n=1066)
203 (19.0)
101 (9.5)
68 (6.4)
III
(n=660)
110 (16.7)
58 (8.8)
34 (5.2) IV
(n=669)
67 (10.0)
36 (5.4)
23 (3.4)
Total
478 (14.4)
249 (7.5)
159 (4.8)
P<.001
P=.002
P=.01

32. 3309 TAAA Repairs Select Rates of Operative Mortality
Subgroups of interest n
Early Death
n (%) P
Patients ≤ 50 y
439
14 (3.2%)
<.001
Patients > 79 y
193
37 (19.2%)
Connective tissue disorder
330
10 (3.0%)
.001
Chronic aortic dissection
1020
58 (5.7%)
.007
Rupture
170
37 (21.8%)
Prior aortic repair
858
70 (8.2%) .4
Elective repair
2586
161 (6.2%)
Urgent or emergent repair
723
88 (12.2%)

33. 3309 TAAA Repairs Early Outcomes by Extent of Repair
All Stroke
n (%)
Stroke, Permanent
Stroke, Temporary I
(n=914)
33 (3.6)
22 (2.4)
11 (1.2) II
(n=1066)
46 (4.3)
36 (3.4)
10 (0.9)
III
(n=660)
9 (1.4)
7 (1.1)
2 (0.3) IV
(n=669)
10 (1.5)
9 (1.3)
1 (0.1)
Total
98 (3.0)
74 (2.2)
24 (0.7)
P<.001
P=.004
P=.04

34. 3309 TAAA Repairs Early Outcomes by Extent of Repair
Spinal Cord Deficits
n (%)
Permanent Paraplegia
Permanent Paraparesis I
(n=914)
71 (7.8)
12 (1.3)
19 (2.1) II
(n=1066)
147 (13.9)
50 (4.7)
35 (3.3)
III
(n=660)
71 (10.8)
29 (4.4)
17 (2.6) IV
(n=669)
27 (4.0)
6 (0.9)
10 (1.5)
Total
317 (9.6)
97 (2.9)
81 (2.4)
P<.001
P=.1

35. Periods Without Permanent Paraplegia
October 1986 to December 2014
Gap of ≥ 50
Date 1
Date 2
Sequential cases without paraplegia 1
Oct 1991
May 1992 69 2
Nov 1992 51 3
July 1993
Apr 1995
261 4
Oct 1995 92 5
Sep 1996
May 1997
117 6
Apr 1998
Feb 1999
113 7
May 1999 8
May 2000
Aug 2000 60 9
Dec 2000
Apr 2001 53 10
Feb 2002
July 2002 84 11
Feb 2003
102 12
Nov 2003
Apr 2004 65 13
June 2004
Dec 2004 62 14
Jan 2007
Dec 2007 90 15
Dec 2010
May 2011 50 16
Mar 2014
Dec 2014 67

36. 3309 TAAA Repairs Early Outcomes by Extent of Repair
Acute Renal Dysfunction
n (%)
Permanent Renal Failure
Temporary Renal Failure I
(n=914)
73 (8.0)
29 (3.2)
16 (1.8) II
(n=1066)
170 (15.9)
78 (7.3)
24 (2.3)
III
(n=660)
81 (12.3)
43 (6.5)
9 (1.4) IV
(n=669)
82 (12.3)
39 (5.8)
12 (1.8)
Total
406 (12.3)
189 (5.7)
61 (1.8)
P<.001
P=.001
P=.6

37. 3309 TAAA Repairs Survivors: Life-Altering Complications by Extent of Repair
Survival with Renal Failure
n (%)
Survival with Permanent Stroke
Survival with Permanent Paraplegia I
(n=914)
12 (1.3)
9 (1.0)
7 (0.8) II
(n=1066)
36 (3.4)
18 (1.7)
25 (2.3)
III
(n=660)
17 (2.6)
4 (0.6) IV
(n=669)
17 (2.5)
3 (0.4)
Total
82 (2.5)
35 (1.1)
52 (1.6)
P=.03
P=.08
P=.001

38. Thoracoabdominal Aortic Aneurysms: Predictors: Multivariate Analysis
Operative Mortality
RRR
p value
Age (by increasing year)
1.05
<.001
Clamp time (by increasing min)
1.01
Rupture
2.38
Renal insufficiency
1.98
.02
Symptomatic aneurysm
1.62
.004
Endarterectomy, stent, or bypass
1.46
Extent IV repair
0.50
0.001
n= 249 cases of operative mortality

39. Paraplegia in Extent II
Thoracoabdominal Aortic Aneurysms Independent Predictors: Multivariate Analysis
Paraplegia in Extent II
RRR
p value
Coronary artery disease
1.92
.03
Chronic aortic symptoms
3.00
.001
Past or current tobacco use
2.75
.1 (NS)
n= 50 cases of permanent paraplegia in extent II TAAA repair

40. Paraplegia in Extent II
Thoracoabdominal Aortic Aneurysms Independent Predictors: Multivariate Analysis
Paraplegia in Extent II
RRR
p value
Coronary artery disease
1.92
.03
Chronic aortic symptoms
3.00
.001
Past or current tobacco use
2.75
.1 (NS)
Genetically triggered disorder
0.23
.05
n= 50 cases of permanent paraplegia in extent II TAAA repair

41. Paraplegia in Extent II
Thoracoabdominal Aortic Aneurysms Independent Predictors: Multivariate Analysis
Paraplegia in Extent II
RRR
p value
Coronary artery disease
1.92
.03
Chronic aortic symptoms
3.00
.001
Past or current tobacco use
2.75
.1 (NS)
Genetically triggered disorder
0.23
.05
Reduces risk by 77%
n= 50 cases of permanent paraplegia in extent II TAAA repair

42. Paraplegia in Extent II
Thoracoabdominal Aortic Aneurysms Independent Predictors: Multivariate Analysis
Paraplegia in Extent II
RRR
p value
Coronary artery disease
1.92
.03
Chronic aortic symptoms
3.00
.001
Past or current tobacco use
2.75
.1 (NS)
Genetically triggered disorder
0.23
.05
Reduces risk by 77%
Reattachment of intercostal or lumbar arteries
0.46
.03
n= 50 cases of permanent paraplegia in extent II TAAA repair

43. Paraplegia in Extent II
Thoracoabdominal Aortic Aneurysms Independent Predictors: Multivariate Analysis
Paraplegia in Extent II
RRR
p value
Coronary artery disease
1.92
.03
Chronic aortic symptoms
3.00
.001
Past or current tobacco use
2.75
.1 (NS)
Genetically triggered disorder
0.23
.05
Reduces risk by 77%
Reattachment of intercostal or lumbar arteries
0.46
.03
Reduces risk by 54%
n= 50 cases of permanent paraplegia in extent II TAAA repair

44. Long-term Survival Survival (%) Follow up (Years) Number at Risk 3309
63.6 ± 0.9
Survival (%)
36.8 ± 1.0
18.3 ± 0.9
All
Follow up (Years)
Number at Risk
3309
1684
724
194

45. Long-term Survival by Age Cohorts
All lines are P < 0.001
(from each other)

46. Long-term Survival by Extent
I/II P < 0.001
I/III P < 0.001
I/IV P < 0.001
II/III P = 0.003
II/IV P = 0.085
III/IV P = 0.270
Survival (%)
Extent I
Extent II
Extent III
Extent IV
Follow up (Years)
Number at Risk
914
525
274 78
1066
539
237 58
660
314
112 28
669
306
101 30

47. Long-term Survival by Rupture
64.9 ± 0.9
Survival (%)
37.6 ± 1.0
18.7 ± 1.0
39.3 ± 4.1
No Rupture
Rupture
20.4 ± 3.6
9.6 ± 3.1
Follow up (Years)
Number at Risk
3139
1634
704
187
170 50 22 7

48. Long-term Survival by Genetic Disorder
82.3 ± 4.1
65.8 ± 2.6
47.4 ± 3.3
Survival (%)
60.3 ± 1.0
32.1 ± 1.0
Genetic Disorder
No Genetic Disorder
14.0 ± 0.9
Follow up (Years)
Number at Risk
523
308
164 60
2786
1376
560
134

49. Long-term Survival by Aortic Dissection
73.7 ± 1.4
52.1 ± 1.7
Survival (%)
58.3 ± 1.1
31.4 ± 2.0
Dissection
No Dissection
29.2 ± 1.1
12.2 ± 0.9
Follow up (Years)
Number at Risk
1196
647
324 97
2113
1037
400

50. Long-term Survival in Those Discharged
With a Life-Altering Complication
P = 0.004
70.5 ± 0.9
Survival (%)
41.2 ± 1.1
48.5 ± 3.6
20.5 ± 1.0
22.0 ± 3.3
No Life Altering
Life Altering
9.9 ± 2.8
Follow up (Years)
Number at Risk
2831
1600
694
186
229 84 30 8

51. Early Survivors by Genetic Disorder
98.1 ± 0.3
96.0 ± 0.6
95.5 ± 0.7
97.1 ± 0.8
92.6 ± 1.6
90.2 ± 2.1
Freedom from Repair Failure (%)
No Genetic Disorder
Genetic Disorder
Follow up (Years)
Number at Risk
2555
1360
545
133
505
301
156 56

52. Freedom from Repair Failure

53. Conclusions
Contemporary TAAA repair yields good-to-excellent outcomes in experienced centers
Results are generally better in younger patients
Patients with Marfan syndrome
Survivors of DeBakey I dissection
Extent I and II
Long-term survival reasonable
Patients are usually > 65 years and generally achieve near life expectancy
Repairs are reliable
Few late events or secondary reinterventions

54. Thank You!
Top Knife