Journal of Vascular Surgery
Volume 43, Issue 2, Supplement , Pages A6-A11, February 2006

Current results of open surgical repair of descending thoracic aortic aneurysms

  • James H. Black III, MD

      Affiliations

    • Johns Hopkins Hospital, Baltimore, Md
    • ,
  • Richard P. Cambria, MD

      Affiliations

    • Massachusetts General Hospital, Boston, Mass
    • Corresponding Author InformationCorrespondence: Richard P. Cambria, MD, Massachusetts General Hospital, WACC 458, 15 Parkman Street, Boston, MA 02114.

Received 17 October 2005; accepted 23 October 2005.

Article Outline

 

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Introduction 

Descending thoracic aortic aneurysms (TAAs) are estimated to affect 10 of every 10,000 elderly adults, with 30% to 40% of these aneurysms being limited to the thoracic aorta.1 Although traditionally viewed as less threatening and less demanding from a technical standpoint than the more extensive thoracoabdominal aneurysms, TAA repair presents the surgeon with a multitude of technical and cognitive challenges that extend through the perioperative period. Improvements in operative care, particularly an aggressive posture toward intercostals preservation and the adoption of protective adjuncts against spinal cord ischemic complications,2, 3, 4, 5, 6 have halved the overall incidence of spinal cord ischemia (SCI) since the Crawford et al benchmark7 series describing a 16% incidence of SCI in 1500 patients. Contemporary reports from centers of excellence detail a consistent overall 5% to 10% risk of SCI.7, 8, 9, 10, 11 Despite considerable progress, no single operative strategy to date has been totally effective in eliminating the problem of SCI and the resultant substantial morbidity that follows TAA repair.

Juvonen et al12 reported on 114 patients with thoracoabdominal aortic aneurysms (TAAAs) managed without surgery and followed over a mean interval of 28 months. Most of the study population did not have large extent TAAAs, but because the threshold for surgery was maintained at 7 cm, the data have important implications. Aneurysm rupture occurred in 23% of their patients, and another 20% had compelling indications for operation, such as pain and leak. Relatively modest mean diameters of 5.8 cm were appreciated in the ruptured thoracic aneurysm patients, and on analysis, pain and chronic obstructive pulmonary disease were associated with an elevated risk of rupture. Given the significant rupture rates with a treatment threshold of 7 cm, this diameter is likely too conservative. In a separate study, the natural history of TAA dictated a 30% 5-year risk of rupture when a TAA is >6 cm, and thus the general recommendation of 6 cm as an appropriate size for repair seems warranted in acceptable-risk patients.13

Despite the variety of operative approaches used in the treatment of TAA, consistent themes with regard to the clinical variables influence both the overall risk of TAA operation and the risk of cord injury. Balancing these risks represents a clinical dilemma for the aortic surgeon, and a thoughtful, logical risk analysis of the individual patient presentation is clearly warranted before repair of TAA. Regarding operative risk, mortality in circumstances other than elective operation is essentially doubled.4, 9 Interestingly, the explanation for this is not so simple as hemodynamic instability, as most patients are stable during their preoperative preparation. Regardless, the association of nonelective operation and perioperative mortality has been verified in many series.3, 4, 9

Renal failure, whether dialysis-dependent or not, has been consistently noted as a predictor of early death.3, 4, 9 Advanced age has also been associated with adverse outcomes in TAA.3, 9, 14 In our view, the patient’s overall functional status appears to be more important than the chronologic age. In support, Huynh et al15 recently reported acceptable perioperative mortality in 63 octogenarians who underwent TAA repair. The perception of unacceptable risk leading to denial of open treatment has, in part, driven the demand for further refinement of surgical technique and alternative therapies for TAA such as endovascular repair.

In this chapter, we review the surgical approaches to TAA and adjunctive methods to decrease end-organ injury and SCI, and examine retrospective reviews of the results of TAA in centers of excellence. Population-based reviews highlight the functional outcomes in broader national samples of TAA, and lastly, new data from prospective registries elucidate the challenges yet to be overcome in the management of patients with aneurysms of the descending thoracic aorta.

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Operative strategy 

In general, strategies to decrease the incidence and severity of end-organ injury and SCI after TAA repair have fallen into two categories. Strategies in the first category are aimed at maintaining visceral and spinal cord blood supply during the course of the operation and include both shunts and bypasses for distal aortic perfusion, preoperative identification of critical intercostal vessels, cerebrospinal fluid drainage, and reconstruction of intercostal arteries.16

The basic premise for distal aortic perfusion is the ability to maintain blood flow to visceral and spinal aortic branch vessels, usually accomplished via partial left heart bypass (LHB) (Fig 1). Clearly, the efficacy of distal aortic perfusion is a function of TAA extent. Those lesions truly isolated to the descending thoracic aorta are clearly amenable to continuous distal perfusion throughout the cross-clamp interval, whereas those lesions that involve the visceral segment, or portions thereof, disallow the same unless a scheme of “octopus” catheters is used. The balance of femoral inflow and the visceral octopus perfusion catheter inflow may invite problematic pressure/volume relationships. Full cardiopulmonary bypass involves significant increases in need for heparinization and the threat of significant blood turnover. LHB via a centrifugal pump carries the advantage of less need for anticoagulation as well as the ability to control distal perfusion pressure.

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  • Fig 1. 

    Open thoracic aneurysm repair accomplished with left heart bypass via left atrial cannula and femoral inflow (preferred approach at Johns Hopkins Hospital). This approach entails posterolateral thoracotomy to achieve surgical exposure. Clamp-and-sew is also a viable alternative if lesion extent or complexity is moderate. (Reprinted from Willams GM and Schlossberg L. Atlas of aortic surgery. Baltimore, Md: Williams and Wilkins, 1997.)

The second general category consists of a wide variety of neuroprotective adjuncts, either pharmacologic agents or variations of hypothermic adjuncts, to attenuate excitatory and inflammatory mechanisms that contribute to the ischemic injury. As shown in clinical reports, specific pharmacologic inhibitors (eg, naloxone) of excitatory neurotransmission decrease spinal cord metabolism.14

Hypothermia may appear to be a nonspecific means of decreasing spinal cord metabolic demand; however, the mechanism may involve a complex interplay of neuronal membrane stabilization, reduced neurotransmission, and decreased oxygen requirement. Beginning in 1993, we have used regional hypothermia with epidural cooling (via an intrathecal catheter) in patients with types I, II, and III TAAs. Our initial experience with 70 patients was compared with 55 historical controls. In this first series, lower-extremity neurologic deficit was significantly reduced in the group treated with adjunctive epidural cooling.3, 17

The approach to TAA repair at the Massachusetts General Hospital has emphasized expeditious restoration of intercostal blood flow in the critical zone of T9 to L1, combined with regional hypothermia of the spinal cord accomplished with epidural cooling, and passive postoperative cerebrospinal fluid drainage.17 LHB is used on a highly selective basis and may be preferred in scenarios of increasing proximal anastomotic complexity (eg, aortic dissection) or in extent I/II TAAA.

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Retrospective review of results in centers of excellence 

Several large retrospective series of isolated TAA repair (not TAAA) are summarized in Table I. These published series reflect state-of-the-art results and demonstrate an admirable incidence of perioperative major morbidity (renal failure and paraplegia) and mortality.18, 19, 20, 21

Table I. Results of open thoracic aneurysm repair
Author, yearPatients (N)Elective/urgent (%)30-day mortality (%)Renal failure (%)Paraplegia (%)Technique⁎
Coselli,18 2004387329/58(17)2.87.42.6LHB, C&S
Estrera,19 2001182182/34(18)8.8NA2.7LHB, CSFD
Galloway,20 19967878/16(20)10.3NA3.8LHB, C&S
Verdant,21 1995366351/15(4)122.40Gott

⁎ Adjunctive techniques: LHB, left heart bypass with distal perfusion; C&S, clamp-and-sew technique; CSFD, cerebrospinal fluid drainage; Gott, 9-mm Gott shunt for distal perfusion; jAAA, juxtarenal AAA.

In the series of Coselli et al,18 their retrospective review compared outcomes of all patients with TAA repaired by use of LHB or by clamp-and-sew techniques. Using propensity scoring and risk stratification analysis, they could not prove that routine use of LHB was more protective against paraplegia than the shorter clamp time and less transfusion-prone clamp-and-sew technique. By this statistical analysis, it would appear LHB and clamp-and-sew techniques can provide equivalent outcomes and both are acceptable operative strategies.18

In the review by Estrera et al, the authors examined those patients with nonemergent (elective) operations.19 In the 105 patients with nonemergent presentations repaired with LHB and cerebrospinal fluid drainage, early neurologic deficits occurred in only 1 patient (0.9%) vs 3 (7.0%) of 43 nonemergent patients repaired without those same adjuncts (P < .04).19 Clearly, these results confirm the ability to reduce the incidence of SCI in the controlled situation of adjunctive methods applied to elective repairs.

Similarly, in the report from Galloway et al,20 the authors detail the risk of death and paraplegia in TAA repair as being related primarily to emergent presentation and not operative technique. Paraplegia occurred in none (0 of 62) their elective TAA patients but in 18.6% of their emergent TAA patients. The operative mortality was markedly elevated by acute presentation (25% vs 6.5% in elective repair).20 The association of emergent presentation and worsened outcomes (pulmonary/SCI/renal impairment) has been confirmed in a large review of 112 patients with acute TAAA by LeMaire et al,22 as well as others.4, 10 Using a technique of passive distal perfusion with a 9-mm Gott shunt, Verdant et al21 reported no cases of postoperative SCI events, a result not subsequently reproduced by other groups. As a possible explanation, the authors highlighted the limited extent of TAA replacement in their series, with 335 (91.5%) of 366 patients undergoing replacement of one third or less of total thoracic aortic length.21 In addition, these limited resections involved few emergent patients, and aortic cross-clamp time averaged 30 minutes (range, 8 to 124 minutes).20 In light of all the aforementioned studies, it is likely that emergent presentations will continue to predict major complications and death, even in experienced hands.

In summary, acceptable outcomes can be achieved through a variety of operative strategies. Surgeon and hospital-related experience (ie, yearly case volume) may be quite important in attempting to extrapolate the exceedingly low incidence of complications and death from the best reports to the daily practice of TAA repair across the United States.

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Population-based studies of outcomes of TAAA repair 

As mentioned, TAAA repair presents a greater threat of renovisceral and spinal complications than TAA repair as a function of the extent of aortic replacement. Yet a look into the broader sample of repaired TAAA patients in state- and nationwide databases reveals the sobering real-life results of the surgical practice of complex aneurysm repair in the last decade.

The incidence of death after TAAA repair may not be captured by a 30-day mortality statistic. In an age-stratified study by Rigberg et al23 of patients who underwent repair of an intact TAAA, statewide 30-day mortality statistics consistently underestimated 1-year survival across age groups. In the 640 total patients who underwent TAAA repair, overall mortality at 1-year was 32% vs only 20% reported in the first 30 days postoperatively.23 The effect was more pronounced in octogenarians, with 28% dying ≤30 days of TAAA repair and 44% by 1 year.23 The authors hypothesized that cardiovascular mortality or other causes continue to claim patients for months after the original operations, and that this is not properly estimated and captured by the accepted reporting standards.23

The University of Michigan group identified greater hospital and surgeon volumes as contributing to improved outcomes in TAAA.24 With 1542 patients, the National Inpatient Sample (NIS) from 1988 to 1998 represents approximately 20% of US hospitals. Within this group, overall mortality for TAAA repair was 22.3%, but did improve over time.24 Significantly, operative mortality was 25.6% for low-volume surgeons vs 11.0% for high-volume surgeons (P < .001).24 Length of stay, mortality, and cardiopulmonary complications were likewise correlated with higher-volume hospitals and surgeons. The authors champion regionalization as a method to improve delivery of care to patients with complex aneurysms.24

Given the sobering mortality data reported by population-based studies, the findings of the Rectenwald et al25 further indicate the need to re-examine the contemporary results of TAAA repair. From their academic medical center, 101 consecutive TAAA patients, including 58 elective repairs and 43 emergent repairs, were reviewed for outcomes at 1 year. A “good” outcome meant being ambulatory or surviving to home or to a rehabilitation hospital; “bad” outcomes included death, discharge to a long-term facility, or being nonambulatory.25 Again, immediate results demonstrated a high overall mortality of 17.8%, with a mean length of stay of 22.8 ± 23.6 days.25 By 1 year, overall survival was only 67%, with barely more than 50% of patients recording a good outcome. Bad outcomes were predicted by age >75 years, duration of visceral ischemia, LHB, and renal dysfunction.25 Eliminating patients with acute presentations raised the good outcomes in the elective subset to 63%. The authors concluded that good outcomes after TAAA repair are significantly less common than acknowledged in the literature and hypothesized that refinement of operative strategy may be needed.25

As a function of a less extensive replacement, TAA repair likely poses less of a perioperative threat than TAAA repair. Nonetheless, the clinical imperative of TAA repair assumes that the risk of operative complications and bad outcomes is outweighed by the aneurysm threat detailed by natural history studies. Yet if the aforementioned TAAA population studies can be extrapolated to TAAs, one may conjecture that even in academic centers across the United States, there is ample opportunity to refine technique and re-examine our risk assessments of TAA repair.

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Recent data from prospective studies 

Randomization of patients with TAA to open or endovascular repair has not been performed to date. However, comparative data from prospective studies of endovascular and open repair may be a better reflection of the contemporary results of surgical practice than can be obtained from population studies, which are substantially limited by coding and reporting errors.

In a study from the Massachusetts General Hospital, 81 patients who underwent stent-graft repair were compared with a concurrent group of 91 patients undergoing open repair of TAA (n = 37) or type I TAAA (n = 54).26 Perioperative mortality in the open cohort (no ruptured TAAs included) was 13.1% vs 8.9% in the stent-graft cohort. Interestingly, in contradistinction to conventional wisdom, paraplegia and paraparesis rates were similar in both groups: 4.5% open and 4.9% stent-graft. Although stent-graft repair was associated with improved early survival, by a mean follow-up of 54 months, the actuarial survival of both cohorts was similar.26

The recently presented phase II study of a thoracic aortic stent-graft approved by the US Food and Drug Administration shed some light on the real-world results of TAA repair. In a cohort-controlled study of 94 patients who underwent open TAA repair, patients were monitored for postoperative events and followed for 2 years for late events such as aortic complications, reinterventions, and survival.27 The results of a group of 140 patients undergoing endovascular thoracic aneurysm repair served as the comparison cohort.28 Seventeen academic centers across the United States participated in the enrollment from 1998 to 2001.

Surgical technique for thoracic aortic replacement included extracorporeal support in 78% patients; spinal drainage was not consistently used.24 Mean age, aortic morphology, and past medical history were all similar between endovascular and open TAA groups. The 30-day mortality was 11.7% in the open TAA “controls” vs 2.1% in the endovascular group. Paraplegia/paraparesis was encountered in 13.8% of the open TAA patients vs 3% of those undergoing endovascular repair. Renal failure was noted in 12% and respiratory failure (>24 hours mechanical ventilation or reintubation) in 20% of open TAA patients vs 1% and 4% in the endovascular group. The authors noted the 13.8% of spinal ischemia was significantly higher than appreciated in the “best” series, and pointed to variable surgeon experience, variable hospital volume, and variable cerebrospinal fluid drainage as likely responsible for the untoward results of open TAA.27 This series represents perhaps the best assessment available of comparative real-world results of open TAA vs stent-graft repair in the nation.

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Future directions in TAA and TAAA repair 

It is clear that impressive reductions in morbidity and mortality have been realized in the arena of complex aneurysm repair, especially in centers of excellence. However, diffusion and adoption of open surgical techniques of TAAA repair across centers has been difficult and may indicate that less stellar results are the norm. Indeed, audited data in the United Kingdom Cardiac Surgical Register, presented by Black et al,29 revealed mortality for replacement of the descending thoracic aorta approaching 34%. The application of stent-graft repair to the more complex TAAAs has been limited by the origin of the visceral vessels off the aneurysm itself.

Single-center reports are now emerging which detail open techniques to ensure end-organ perfusion via surgical bypasses and subsequent stent-graft coverage of significant lengths of thoracovisceral aorta. The results of these studies are summarized in Table II.29, 30, 31

Table II. Results of “hybrid” thoracoabdominal aortic aneurysm revascularization and endovascular repair
Author, yearPatient (N)Extent (N)F/U (months)30-day mortalityType I or III leak (%)Complication (N)Paraplegia (%)
Flye,29 20043III, IV, patch11-21033(III)TIA (1)0
Fulton,30 200510IV(2)0-13010(I)CV (2); Pulm (2)0
jAAA(8) GI(1)
Black,31 200529I (3)2-2815%23(I)CV (7); Pulm (9)0
II (18) 4(III)Renal 4; GI (3)
III (7)
IV (1)

TIA, Transient ischemic attack; CV, cardiovascular; GI, gastrointestinal.

A key tenet of the surgical aspects of the “hybrid” exclusions is the performance of individual bypasses to the visceral branches with ligation of the origins to prevent type II endoleak (Fig 2, Fig 3); in either the same procedure as the surgical revascularization or in a staged fashion days later, the endograft is inserted to cover the aneurysmal thoracovisceral aorta. In endovascular exclusion, proper fixation zones and substantial overlap of endoprostheses are mandatory to withstand the substantial hemodynamic forces present. In the series of Flye et al29 and Black et al31 it was not uncommon for four to seven pieces to be placed in a single patient. Although the occurrence of more type I and III endoleaks can be expected in such cases, most of them would seem to be correctable with secondary, “nonsurgical” endovascular procedures. Clearly, long-term data regarding this very creative approach to extensive TAAAs are lacking, yet the complication rates (particularly SCI, paraplegia, and paraparesis) compare favorably with series detailing open TAAA repair.6, 7, 8, 9, 10, 11

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  • Fig 2. 

    Angiogram of completed “hybrid.” Bypass grafts are evident to left renal artery and superior mesenteric artery via a single limb and separate limb to hepatic and right renal arteries. (Courtesy Patrick Geraghty, Washington University School of Medicine.)

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Conclusions 

Open surgical repair of TAA is known to be durable with a low incidence of secondary aortic interventions. Graft-related complications per se, such as infection or anastomotic aneurysm, are very rare; secondary interventions occur in approximately 10% of patients and are usually located in noncontiguous aortic segments.32 Although considerable progress has been made in diminishing the incidence and severity of postoperative renovisceral and spinal complications, no strategy to date has eliminated them. Based on single-center retrospective reviews and population data, acute presentations of TAA portend arduous postoperative courses and adversely impact long-term functional outcomes. Surgeon-related case volumes may also merit examination and motivate regionalization of complex aneurysm surgery to improve outcomes.

As comparative studies of open TAA repair and stent-graft repair emerge, endovascular repair will likely continue to demonstrate impressive reductions in overall perioperative morbidity and mortality, albeit with an assumed increase in the need for secondary aortic interventions. However, for some patients with more extensive aneurysms who are at high risk for complications, variations in open surgical techniques to maintain end-organ perfusion and achieve “hybrid” endovascular reconstruction of TAA and TAAA are more likely to become complementary and not mutually exclusive.

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References 

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  17. Black JH , Davison JK , Cambria RP . Regional hypothermia with epidural cooling for prevention of spinal cord ischemic complications after thoracoabdominal aortic surgery . Semin Thorac Cardiovasc Surg . 2003;15:345–352 Review
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  28. Makaroun MS , Dillavou ED , Kee ST , Sicard G , Chaikof E , Bavaria J , et al.  GORE TAG Investigators   Endovascular treatment of thoracic aortic aneurysms (results of the phase II multicenter trial of the GOR TAG thoracic endoprosthesis) . J Vasc Surg . 2005;41:1–9
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  30. Fulton JJ , Farber MA , Marston WA , Mendes R , Mauro MA , Keagy BA . Endovascular stent-graft repair of pararenal and type IV thoracoabdominal aortic aneurysms with adjunctive visceral reconstruction . J Vasc Surg . 2005;41:191–198
  31. Black SA, Wolfe JHN, Clark M, Hamady M, Cheshire NJW, Jenkins MP. Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization. Presented at Society for Vascular Surgery, 2005; Chicago, Ill.
  32. Clouse WD , Marone LK , Davison JK , Dorer DJ , Brewster DC , LaMuraglia GM , et al.   Late aortic and graft-related events after thoracoabdominal aneurysm repair . J Vasc Surg . 2003;37:254–261

 Competition of interest: none.

PII: S0741-5214(05)01862-8

doi:10.1016/j.jvs.2005.10.047

Journal of Vascular Surgery
Volume 43, Issue 2, Supplement , Pages A6-A11, February 2006

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