Journal of Vascular Surgery
Volume 48, Issue 4 , Pages 828-835.e1, October 2008

Functional outcome after thoracoabdominal aneurysm repair

Presented at the Twentieth Annual Meeting of the Eastern Vascular Society, Washington, DC, Sep 28-30, 2006.

Division of Vascular and Endovascular Surgery of the General Surgical Services, Massachusetts General Hospital and Harvard Medical School, Boston, Mass

Received 8 February 2008; accepted 10 May 2008. published online 28 July 2008.

Article Outline

Objectives

Previous reports have documented perioperative outcomes and major complications (renal failure, spinal cord ischemia, death) after repair of aneurysms of the thoracoabdominal aorta (TAA). This study documented long-term functional outcomes after open TAA repair.

Methods

The Medical Outcomes Study Short-Form 36-Item Survey (SF-36) was administered to 134 survivors (83 men, 51 women; mean age, 69.5 years) of TAA repair at a mean follow-up from surgery of 60 ± 38.7 months. Raw scores were compared against cohorts adjusted for age and comorbidity (cardiovascular disease). Assessed was the influence of preoperative and intraoperative factors, as well as postoperative complications on long-term quality of life (QOL).

Results

Raw scores for the eight SF-36 domains and the composite physical and mental component scores were lower (P < .01) in the TAA cohort compared with an age-adjusted reference population. Female gender and age >75 years decreased the physical functioning (P = .02) and role physical (P = .04) domains compared with male gender and patients <65 years old. Previously recognized systemic vascular disease lowered QOL in three SF-36 domains: general health (P = .013), social functioning (P = .003), and role emotional (P = .003); systemic vascular disease also showed a strong trend toward reduction in physical functioning (P = .09) compared with patients without systemic vascular disease. Neither TAA extent (I to IV) nor elective vs urgent/emergency operation influenced long-term QOL in our cohort. Patients with postoperative paraplegia, cerebrovascular accident/cardiac event, and those requiring reoperation showed lower scores in the physical functioning (P = .036), general health (P = .02), and Mental Health (P = .04) domains. Increased length of stay negatively impacted long-term QOL. The TAA cohort and the cardiovascular disease cohort had similar SF-36 scores for four domains (general health, bodily pain, vitality, and social functioning) and physical component scores. The cardiovascular disease group had higher scores in the physical functioning, role physical, role emotional, and mental health domains, and in mental component scores (P < .01).

Conclusion

Permanent loss of functional capacity, measured at a mean of 5 years postoperatively, occurs rarely in survivors of TAA repair. Further studies are needed to define the role of hybrid or endovascular strategies, including their impact on long-term functional outcome compared with open TAA repair.

 

We, and others, have previously reported on the perioperative outcomes after repair of aneurysms of the thoracoabdominal aorta (TAA), emphasizing the significant impact of major complications, in particular, renal failure and spinal cord ischemia.1, 2, 3, 4, 5, 6 A recent report found mortality of 19% at 31 days and 31% at 365 days, with an increasing mortality rate at 30 and 365 days for patients that was linearly related to increasing age.7 Other reports have suggested that outside of centers of excellence, the operative mortality for nonruptured TAA repair can approach 25%,8 yet the natural history of TAA without resection is dismal. A previous report of nonoperative management of TAA placed 5-year survival rates at 39% and repair-free survival rates at 17% at 5 years; a second study reported 20% mortality from rupture for patients monitored nonoperatively for 1 year.9, 10

There is consensus that patients with a life expectancy >2 years, who are reasonable operative candidates, and whose TAA is >6 cm in diameter should undergo elective TAA resection. Furthermore, reluctance to proceed with timely resection comes at the expense of increased morbidity when TAA repair is conducted in urgent circumstances. Several reports have documented that overall morbidity (including spinal cord ischemia) and mortality are increased in the roughly 20% of patients who undergo TAA resection in urgent circumstances.1, 2

Despite the evident focus on perioperative outcomes, late survival in our TAA cohort compared with that achieved after abdominal aortic aneurysm (AAA) repair is acceptable, demonstrating that the substantial resource investment in bringing these patients through TAA repair is appropriate.1 However, it is also clear that prolonged or incomplete recovery can hamper late functional outcomes. Rectenwald et al11 reported satisfactory outcomes at 1 year in only 63% of patients after TAA repair, albeit their data was influenced by an 18% operative mortality.

Quality of life (QOL) measures have assumed increasing importance, in particular in the era when endovascular repair for TAA is available. Although QOL assessment after a variety of interventions for vascular disease has proven to be a useful tool, it can be argued that recovery after carotid endarterectomy (CEA) or even AAA bears little relevance to functional outcome after TAA repair. This relates, of course, to both the magnitude of formal open TAA repair and the particular potentially devastating impact of spinal cord ischemia. Such investigation is particularly relevant in an era when hybrid operations have been applied to TAA repair with the intent of reducing operative morbidity.12, 13, 14 From an anecdotal perspective that most patients do achieve complete recovery after TAA repair, the purpose of this study was to document long-term quality of life after open TAA repair.

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Methods 

Patient cohort and characteristics 

During the interval January 1987 to June 2005 (to insure minimum 2-year follow-up), 435 patients underwent surgical repair of TAA. Details of techniques used for repair and outcomes have been reported previously.1 Institutional Review Board approval was obtained for all aspects of this study. The Social Security Death Index database was used to identify 204 of 435 survivors of TAA repair, and contact information was obtained from hospital and office records.

A license for the United States English version of the Medical Outcomes Study Short-Form 36-Item (SF-36) Health Survey (version 2) standard form was obtained from QualityMetrics Inc (Lincoln, RI), and a copy with a return envelope was mailed to all identified survivors; there were 134 respondents (67% response rate). The mean follow-up time from surgery to survey answering was 60 ± 38.7 months after TAA repair.

Clinical and demographic features of the 134 respondents and of the entire TAA cohort are detailed in Table I, with definitions as reported previously.1 Only a lower incidence of chronic obstructive pulmonary disease and truly elective operation distinguished the respondents from the overall TAA repair cohort. For TAA extent, we have applied the original E. S. Crawford definitions: the entire descending aorta needs to be resected to be classified as TAA extent I or II; thus, the single greatest percentage of patients throughout our experience has been extent III.1 Major postoperative complications (mortality, paraplegia and renal failure, as summarized elsewhere1) were not significantly different between respondents and the overall cohort.

Table I. Demographic and clinical features of 134 quality of life respondents and overall thoracic aortic aneurysm cohort
VariableaQOL respondentsTAA cohortP
Total patients, No.134435
Age, years69.52±10.33(30-90)70.79±9.53(17-90).17
Male sex61.9(83/134)48.7(212/435).0014
Diabetes6.7(9/134)7.1(31/434).88
Hypertension85.1(114/134)87.4(380/434).58
COPD34.4(46/134)50.1(218/434).002
CAD98.5(132/134)98.6(429/434).14
Prior vascular surgery
CABG17.2(23/134)14.5(63/434).72
Carotid12.7(17/134)21.6(94/434).024
PVD3.7(5/134)5.1(22/434).54
Prior aortic surgery
Infrarenal AAA20.9(28/134)19.3(84/433).82
Thoracic aortic
Aneurysm3.0(4/134)6.7(29/434).11
Prior TAA9.7(13/134)7.1(31/434).11
Prior aortobifemoral5.2(7/134)2.5(11/434).66
TAA extent
Type I29.9(40/134)27.1(118/435).11
Type II11.2(15/134)15.2(66/435).66
Type III31.3(42/134)36.3(158/435).34
Type IV27.6(37/134)21.4(93/435).17
Symptomatic at operation26.1(35/134)36.6(158/432).030
Urgent/emergency operation12.7(17/134)23(97/435).02
Intraoperative variables
Epidural coolingb65.7(88/134)57.2(249/435).093
Total operative time, min315.7±93.1(153-715)313.7±95.8(120-715).99
Total cross-clamp time, min78.8±29.5(24-193)76.7±30.1(23-341).42

AAA, Abdominal aortic aneurysm; CABAG, coronary artery bypass grafting; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; PVD, peripheral vascular disease; TAA, thoracoabdominal aneurysm.

aContinuous data are presented as mean ± standard deviation (range); categoric data as percentage (number).

bFor spinal cord protection.

QOL measurements 

QOL was assessed using the SF-36 questionnaire, which consists of 36 questions that measure eight different health domains of QOL. These domains are physical functioning, role limitations as a result of physical problems (role physical), bodily pain, general health perception, vitality (the frequency of feeling full of energy or feeling tired), social functioning, role limitations resulting from emotional problems (role emotional), and general mental health. The SF-36 has been extensively studied and validated in many disease models for assessing QOL in these eight domains.15 A description of the SF-36 domains is provided in Appendix (online only).

Data from the surveys was transformed using a conversion table and entered into software provided by QualityMetrics. Norm-based (raw) scores for the eight SF-36 QOL domains were obtained using this method. For each domain, a raw score was transformed to a 0 to 100 scale (transformed scores), with 100 representing optimal functioning. Two component scores, the physical component score and the mental component score, are derived from the eight SF-36 domains and are also reported. The physical component score reflects physical morbidity and etiology, and the mental component score reflects psychologic or mental morbidity and etiology (Table II, online only). Scores are reported with a 95% confidence interval (CI).

Table II. Quality of life scores for patients after thoracoabdominal aneurysm repair
SF-36 domainsTransformed scoresNorm-based scores (NBS)Age-adjusted NBSaDifference from age-adjusted NBS
Mean (95% CI)Mean (95% CI)Mean (95% CI)Mean (95% CI)
Physical functioning46.7(41.9-51.5)34.6(32.6-36.6)44.5(43.7-45.2)9.8(7.8-11.9)b
Role physical44.1(39.1-49.0)34.9(33.0-36.9)45.5(44.8-46.3)10.6(8.6-12.6)b
Bodily pain59.9(55.1-64.8)45.2(43.1-47.2)47.8(47.1-48.5)2.6(0.46-4.8)b
General health54.5(50.8-58.2)42.2(40.2-44.3)48.4(47.7-49.1)6.2(4.3-8.1)b
Vitality48.0(46.4-49.6)44.9(44.1-45.7)51.6(50.9-52.3)6.7(5.0-8.5)b
Social functioning70.8(65.7-75.9)44.1(41.9-46.3)50.1(49.4-50.8)6.0(3.6-8.3)b
Role emotional66.3(60.8-71.8)40.1(37.6-42.7)48.6(47.9-49.4)8.5(5.8-11.1)b
Mental health55.4(53.1-57.7)39.0(37.7-40.2)52.7(52.1-53.3)13.8(12.3-15.2)b
Composite score
Physical 39.0(37.0-41.0)44.7(44.0-45.4)5.7(3.5-7.9)b
Mental 43.6(42.4-44.8)53.17(52.5-53.8)9.6(8.2-10.9)b

CI, Confidence interval; SF-36, Medical Outcomes Study Short-Form 36-Item Health Survey.

aObtained from SF-36 interpretation manual.16

bP < .01.

Intracohort analysis 

Several preoperative, intraoperative, and postoperative variables were examined for their influence on QOL after TAA repair, including age at operation, gender, history of operation for systemic vascular disease, defined as coronary artery bypass graft (CABG), CEA, or lower extremity distal bypass; urgency of operation (urgent/emergency vs elective procedures), and TAA extent I to IV. Postoperative variables examined were major neurologic deficit (postoperative paraplegia vs no neurologic event), hospital length of stay (≥20 hospital days vs <20 days in the hospital), patients with and without a postoperative cerebrovascular accident (CVA)/cardiac event, and patients with and without reoperation of any kind. Transformed scores were used for these comparisons.

Comparison with reference cohorts 

Because preoperative SF-36 data were not available for our TAA cohort, relevant comparison groups were sought. First, the average age of our TAA cohort was 69.5 years; consequently, we first compared our TAA cohort with age-matched norm-based data provided in the SF-36 manual.16 Second, reference SF-36 data are representative of the 1998 general US population. Even when corrected for age, and given the multiple comorbidities of our study population, this cohort was hardly an ideal reference standard for a cohort in need of TAA repair. Accordingly, a norm-based cohort of 658 patients with self-reported medication required for cardiovascular disease or with limiting cardiovascular disease was provided by QualityMetrics (unpublished data). Indeed, the defining clinical/demographic characteristics of this cohort (mean age, 65 years, 50% women, and 58% hypertension) compared well with our TAA cohort (Table I). Furthermore, our TAA cohort was composed of 98.5% of patients who we classified as having cardiovascular disease based on a history of previous myocardial infarction, electrocardiographic evidence of a previous cardiac ischemia, or previous/current active cardiac symptoms. Accordingly, the comparison between this chronic disease cohort and our TAA cohort was the best available control cohort.

Statistical analysis 

The QOL data for intracohort analysis are presented as mean (transformed scores) ± standard error. For the purpose of comparison between predefined groups, t test and analysis of variance were used. The adjusted comparison for age and gender was done by means of analysis of covariance. Norm-based (raw) scores are used for comparison to reference cohorts and are presented with 95% CIs. Differences from the norm-based groups are expressed as the mean difference with 95% CI. For comparisons among our TAA cohort, age-adjusted, and cardiovascular groups, the t test with Welch correction was applied. A value of P < .05 was considered statistically significant. For statistical analysis, we used SAS 8 software (SAS Institute Inc, Cary, NC). SF-36 data were analyzed using software provided by QualityMetrics.

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Results 

Outcomes for TAA cohort 

Table II reports transformed scores, norm-based raw scores (including physical and mental component scores), age-adjusted norm-based scores provided in the SF-36 manual,16 and statistical differences between the TAA and age-adjusted groups, all with 95% CIs. Norm-based scores for the eight domains and the physical and mental component scores were significantly lower (P < .01) in our TAA cohort compared with the age-adjusted reference population.

Intracohort comparisons for preoperative variables on QOL 

Gender 

After correcting for age within our study population, physical functioning was significantly lower in women compared with men (P = .02). None of the other SF-36 domains showed significant differences when men vs women undergoing TAA repair were compared.

Age at surgery 

After correcting for sex within our study population, role physical was significantly lower in patients aged >75 years compared with patients <65 years at the time of operation (P = .04). None of the other SF-36 domains showed significant differences between the different age groups.

Influence of systemic vascular disease 

Fig 1 illustrates the influence of systemic vascular disease on QOL after TAA repair. QOL scores in patients with previously recognized systemic vascular disease were lower in seven of eight categories, three of which achieved statistical significance: general health (P = .013), social functioning (P = .003), and role emotional (P = .003). Although not statistically significant, physical functioning showed a strong trend towards reduction in patients with previous systemic vascular disease (P = .09). Paradoxically, the mental health score was significantly higher in patients with previously recognized systemic vascular disease (P = .02).

  • View full-size image.
  • Fig 1. 

    Influence of systemic vascular disease (SVD) on quality of life after thoracoabdominal aneurysm repair as assessed by scores on the domains of the Medical Outcomes Study Short-Form 36-Item (SF36) Health Survey at mean 5 ± 3.2 years after operation. Data are shown with the standard error.

Influence of TAA extent 

Because the extent of operation can influence overall recovery, we examined the influence of TAA extent on QOL after TAA repair. No significant differences were detected in any of the eight domains of the SF-36 amongst patients with the four different TAA extents.

Elective vs urgent/emergency operation 

No significant differences were found in any of the eight domains of the SF36 when elective vs urgent/emergency TAA repairs were compared.

Postoperative variables and QOL 

Months of follow-up after the procedure 

Fig 2 illustrates the influence of follow-up time on the different SF-36 QOL domains after TAA repair. There was no difference in seven of eight SF-36 domain scores as a function of follow-up interval after operation. In the physical functioning domain, patients surveyed >7 years after operation showed a significant decline compared with patients with a shorter follow-up (P = .005).

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  • Fig 2. 

    Influence of follow-up time on quality of life after thoracoabdominal aneurysm repair as assessed by scores on the domains of the Medical Outcomes Study Short-Form 36-Item (SF36) Health Survey. Data are shown with the standard error.

Complications 

Fig 3 illustrates the influence of paraplegia on QOL after TAA repair. Not surprising, the physical functioning domain was significantly lower in patients with postoperative paraplegia (P = .036), but perhaps surprisingly, no statistically significant change was found in other SF-36 domains. Patients with a postoperative CVA/cardiac event and those who required reoperation showed a significantly lower score in the general health (P = .02) and mental health (P = .04) categories compared with those free of these complications.

  • View full-size image.
  • Fig 3. 

    Influence of post-operative paraplegia on quality of life after thoracoabdominal aneurysm repair as assessed by scores on the domains of the Medical Outcomes Study Short-Form 36-Item (SF36) Health Survey. Note the small numbers of late survivors after total paraplegia. Data are shown with the standard error.

Hospital LOS 

Fig 4 shows the influence of LOS on postoperative QOL. Although not statistically significant, two different domains showed strong statistical trends. Values for both physical functioning and role physical were higher in patients who stayed in the hospital for ≤20 days vs those that stayed in the hospital for >20 days (P = .07 and P = .08, respectively).

  • View full-size image.
  • Fig 4. 

    Influence of hospital length of stay on quality of life after thoracoabdominal aneurysm repair as assessed by scores on the domains of the Medical Outcomes Study Short-Form 36-Item (SF36) Health Survey. Prolonged hospitalization may be a surrogate for poor physical functioning domains. Data are shown with the standard error.

Comparison with cardiovascular disease cohort 

Table III reports norm-based scores for our TAA cohort and the cardiovascular disease cohort. Four domains showed significantly (P < .01) higher scores for the cardiovascular disease group: physical functioning, role physical, role emotional, and mental health. The scores for the four domains general health, bodily pain, vitality, and social functioning were not different between the groups. The physical composite score showed no difference between the two groups, whereas the mental composite score was higher (P < .01) in the cardiovascular disease group.

Table III. Comparison of quality of life norm-based scores between thoracoabdominal aneurysm and chronic disease cohort
SF-36 dimensionsTAA cohortCardiovascular cohortDifference from cardiovascular cohort
Mean (95% CI)Mean (95% CI)Mean (95% CI)
Physical functioning34.6(32.6-36.6)38.9(38.0-39.7)4.3(2.1-6.4)a
Role physical34.9(33.0-36.9)40.1(39.3-40.9)5.2(3.1-7.2)a
Bodily pain45.2(43.1-47.2)43.6(42.8-44.3)NS
General health42.2(40.2-44.3)40.9(40.1-41.6)NS
Vitality44.9(44.1-45.7)45.4(44.6-46.1)NS
Social functioning44.1(41.9-46.3)44.2(43.3-45.0)NS
Role emotional40.1(37.6-42.7)43.6(42.6-44.6)3.4(0.7-6.2)a
Mental health39.0(37.7-40.2)48.5(47.7-49.3)9.5(8.0-11.0)a
Physical composite score39.0(37.0-41.0)38.9(38.1-39.7)NS
Mental composite score43.6(42.4-44.8)48.3(47.5-49.2)4.7(3.3-6.2)a

NS, Not significant; SF-36, Medical Outcomes Study Short-Form 36-Item Health Survey; TAA, thoracoabdominal aneurysm.

aP < .01.

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Discussion 

Open TAA repair, particularly the more extensive extent I and II repairs, entails considerable morbidity and prolonged recovery in many patients; the literature has largely focused on perioperative outcomes and late survival.1, 2, 3, 4, 5, 6 In prior reports we demonstrated an overall perioperative mortality of 8%, a 13.5% incidence of lower extremity neurologic deficit of any severity, equivalent late survival to that expected after AAA repair,17 and favorable durability of TAA repair.1, 17, 18 These studies documented that the considerable resource allocation to bring patients through a TAA operation was appropriate, particularly when contrasted with the natural history of TAA.9, 10

Unlike AAA repair options, open repair was the only technical option for TAA until recently.12 As endovascular options for TAA repair emerge, comparative functional outcome assessments will assume increasing importance in the selection of conventional vs hybrid/stent graft options in individual patients. Because virtually no information is available on functional outcomes after open TAA repair, we assessed this at a mean follow-up duration of 5 years after operation to determine if, and how often, permanent loss of functional capacity occurs after open TAA repair.

The available literature referable to QOL after TAA repair has focused primarily on the effects of cardiopulmonary bypass on assessing, in particular, cognitive functioning in the elderly.19, 20, 21 To our knowledge, aside from a recently published small report on QOL after TAA, this is the largest series of patients assessed for QOL after TAA repair in the literature.

Eide et al22 used the SF-36 to document health-related QOL in 11 survivors of TAA repair at mean follow-up of 6.2 years. Comparison was made against a cohort from the general population. In general, SF-36 scores for the TAA cohort were lower in all dimensions compared with the reference population. It is important to note that this reference population was controlled for age—but not for comorbid conditions—which significantly affect measurements of QOL. The five patients who had postoperative complications scored lower in the physical dimensions. The six patients with uncomplicated postoperative courses all reported improved health status compared with their preoperative status. More important, 10 of 11 patients, which included patients with decreased measured health-related QOL, still evaluated their operation as successful in an additional questionnaire.22 Zierer et al, recently reported on late functional outcomes after elective surgery for thoracic aortic aneurysms. The final data included SF-36 analysis, during the interval: 35 ± 20 months post-operatively, on 20 ascending, 25 descending and 25 thoracoabdominal aneurysms. Data for the thoracoabdominal group showed norm-based scores significantly below the 50% percentile in all SF-36 categories, except mental health. Survival and quality of life in the physical domains were lowest with thoracoabdominal patients when compared with ascending and descending aneurysms. Interestingly, functional status was not affected by advanced age.23

Summary, norm-based scores were significantly lower in our TAA cohort than those reported for the age-adjusted norm in all categories. Given the nature of the surgical procedure, it is not surprising that this is the case. A study of 111 patients after thoracic aortic surgery showed that patients aged 65 to 75 years had significantly lower scores in four SF-36 domains compared with an age- and gender-matched cohort.21 In a similar study of 76 survivors of thoracic aortic surgery, mean differences from the norm ranged from 0.1 in the bodily pain domain to 30.2 in the role physical domain (transformed scores), with only the bodily pain domain not falling significantly below the norm.24 However, patients in this study had thoracotomy incisions only, likely without paralysis of the left hemidiaphragm, which occurs frequently in patients with thoracoabdominal incisions done for TAA repair. These results underline one difficulty in interpreting SF-36 data, which is that significant differences in numeric raw scores may not correspond to significant differences in some clinically relevant outcomes that are important in the assessment of QOL.

Overall, after correcting for age within our cohort, men had higher QOL scores in six of eight domains compared with women, with the physical functioning domain achieving statistical significance. Given that within our respondents group 61.9% were men, yet men comprised only 48.7% of the entire TAA group, our mean SF3-36 scores may overestimate the long-term functional outcome of TAA survivors. These results are concordant with previous QOL literature. Female gender was a negative predictor of several parameters of QOL 1 year after CABG in a cohort of 96 women, even after correcting for well-known risk factors affecting QOL.25 Similar results have been seen in other studies for patients after CABG26, 27 and after surgery for non-vascular-related conditions such as colon cancer.28 A difference in physical reserve between men and women may explain the improved ability of men to tolerate open TAA repair, although the reasons for the gender-related discrepancies in SF-36 scores remains speculative. Moreover, such gender-specific outcomes are of major importance in consideration of TAA repair because a consistent nearly 50% of our patients have been women (Table I).

Age clearly influences QOL evaluated using the SF-36 and physical health measures.16 It is therefore anticipated that age at operation significantly influenced the outcome of the role physical dimension, and that a similar trend, although not significant, was observed in the physical functioning domain. Although age per se has not been considered a contraindication to TAA repair, others have correlated poor outcomes with increased age at operation.4, 7 Our posture has been that octogenarians must have normal renal function, favorable functional status, and favorable objective cardiopulmonary profiling to undergo elective TAA repair. Developing such guidelines is particularly important given that 13% of patients in our series were ≥80 years old at operation.1

After correcting for sex and age, QOL scores in patients with previous CABG, CEA, or peripheral vascular disease surgery were lower in seven of the eight SF-36 domains. Paradoxically, patients in the surgical group had a statistically higher mental health score compared with patients with no previous surgery. This may reflect better coping mechanisms for these patients who have been through previous cardiovascular surgery. Our results are consistent with previous reports. In one report, SF-36 scores for patients with coronary artery disease before CABG were lower in all domains of the SF-36, with some improvement after CABG.29 Subjects with intermittent claudication have significantly worse median health-related QOL scores than patients without claudication, specifically in the physical domains of the SF-36.30 Even subjective pain from PAD has been shown to have a negative influence on QOL scores.31

In an attempt to clarify clinical and postoperative variables potentially correlated with late functional outcome, our results were perhaps counterintuitive in certain domains. For example, extent IV TAAs have a modest (3%) incidence of spinal cord ischemic complications, the lowest perioperative mortality, and the least extent of surgery. Yet, extent of TAA repair did not influence any of the eight domains of QOL, perhaps related to the late time interval after operation at which our patients were assessed. A relevant consideration on late outcomes is the clinical circumstances of operation, because we and others have documented the increased risk of complications that accompanies nonelective operation.1, 2, 5

Rectenwald et al11 previously examined the influence of urgency of operation on functional outcome after TAA repair. Their review dichotomized functional outcomes as “good” and “bad” at 1 year, as follows: outcome was good if the patients were ambulatory or living at home and bad if the patients were nonambulatory or living in a long-term care facility. Urgency of operation in their cohort was a univariate predictor of a bad outcome at the 1-year follow-up, because nearly 60% of their patients who had an urgent operation had a bad outcome at 1 year.11

Our data revealed no differences in QOL between patients whose TAA was treated as an urgent or emergency procedure and those treated in elective circumstances. The lack of functional outcome difference between these two groups may be because any differences related to the urgency of the operation were already minimized by the time the survey was completed. Differences in the mean follow-up in our cohort of 60 months compared with 12 months, or the percentage of patients treated for actual rupture, or both, likely account for the discrepant data.

The major postoperative complications of paraplegia and renal failure have previously been shown to negatively influence operative mortality and late survival.1, 4, 6 By extension, it would appear logical that a similar—or even more dramatic—influence on late functional outcome would be evident. Patients with postoperative paraplegia, as expected, had a significant decrease in the physical functioning domain, but perhaps surprisingly, had no significant change in seven of eight domains when compared with patients with no spinal chord ischemia complications. Most likely, the inability to attain statistical significance (scores in seven of eight domains were lower for the major deficit group) is related to a power issue; however, this question cannot be fully answered until a larger sample can be analyzed. Patients with a major cardiac event or a stroke had significantly lower general health scores and mean scores were lower in five of eight SF-36 categories.

Related studies have showed conflicting data when the influence of major complications on QOL was examined. Rectenwald et al11 found a significant increase in “bad outcomes” (as defined above) for patients with spinal cord injury at discharge from the hospital. At 1 year, scores were still lower for patients with spinal cord injury, but this difference did not reach statistical significance.11 Olsson et al,24 in their review of 76 survivors of thoracic aneurysm repair, concluded that postoperative complications, including neurologic insults, did not appear to affect long-term QOL in a predictable fashion. For our cohort, the negative impact of a major postoperative complication (paraplegia or cardiac/CVA) appears to persist, even at 60 months of mean postoperative follow-up. To our knowledge, these data are the first to document this perhaps anticipated effect of major perioperative complications.

Within our cohort, patients monitored for >82 months after operation showed a statistically significant decline in the physical functioning domain. The lower scores at longer follow-up time may be a consequence of overall cardiovascular disease or indeed a concept as simple as “aging.”

Reoperation of any kind showed lower scores for five of eight domains and a statistically significant decrease in the mental health domain. This was consistent with the study by Rectenwald et al,11 where reoperation predicted a “bad outcome” both at discharge from the hospital and at 1-year follow-up. In a previous study, we documented an overall 10% “late aortic event” (additional aneurysm resection or graft-related complication) at a mean follow-up interval of 30 months after TAA repair.18 Accordingly, the negative effect on QOL of potential secondary operation must be considered when clinical decisions such as extent of resections are formulated. In current practice staged approaches to diffuse aneurysmal disease will clearly involve the potential for secondary (or primary) stent graft repair.

A limitation of our study is the failure to obtain preoperative SF-36 profiling. Such data would have allowed us to more precisely assess the influence of the operation alone on QOL by controlling for pre-existing and chronic disease factors. Furthermore, by virtue of study interval after operation, our report focuses on late outcomes rather than the impact of early postoperative recovery. Yet, the former consideration is of greater clinical importance because it can be assumed that the early recovery after open TAA repair is indeed onerous.

The absence of a precise reference population for comparison with our TAA cohort constrains our data. In lieu of preoperative SF-36 scores, the cardiovascular disease cohort appears to be a relevant control. Indeed, four of eight SF-36 domains, and the physical component score, showed no significant change between the cardiovascular cohort and our TAA cohort. Furthermore, in the four domains that showed decreased values for the TAA cohort, all decreases were <10 points, which have been argued as nonclinically relevant using this tool.22 Given the data, long-term functional status in our TAA cohort is comparable with a matched comorbid disease cohort.

Finally, the data may be biased in the process of clinical decision making; that is, whether or not to recommend operation. It is incorrect to assume that operation was only recommended in the circumstance where full functional recovery was anticipated: a full 22% of patients in our experience were treated in urgent/emergency circumstances of actual or threatened rupture.

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Conclusion 

These data permit the conclusion that permanent loss of functional capacity, measured at a mean of 5 years after operation, occurs rarely in survivors of TAA repair. Prospective comparative studies will be required to define the role of alternative surgical strategies for TAA repair and their impact on long-term functional outcome compared with open TAA repair.13

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Author contributions 


Conception and design: RSC, MFC, RPC

Analysis and interpretation: RSC, JP, TC, MC, MFC, RPC

Data collection: RSC, JP, MC

Writing the article: RSC, RPC

Critical revision of the article: RSC, TC, MC, MFC, RPC

Final approval of the article: RSC, JP, TC, MC, MFC, RPC

Statistical analysis: RSC, JP, TC, MFC, RPC

Obtained funding: RPC

Overall responsibility: RSC, RPC

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Appendix (online only) 

Appendix (online only). Categories of the Medical Outcomes Study Short-Form 36-Item Health Survey that describe overall health status
DomainsAbbreviationDomain assessedMeaning of score improvement
Physical functioningPFPhysical limitations in performance of daily living.Performs all types of physical activities including the most vigorous without limitations as a result of health.
Role physicalRPProblems encountered with daily activities or work as a result of physical health.No problems with work or other daily activities as a result of physical health.
Bodily painBPOverall pain severity.No pain or limitations resulting from pain.
General healthGHOverall general health.Evaluates personal health as excellent.
VitalityVTFrequency of feeling full of energy vs. tired.Feels full of energy or pep all the time.
Social functioningSFPerformance of social activities in lieu of health problems (eg, osteoarthritis).Performs social activities without interference as a result of physical or emotional problems.
Role emotionalREProblems encountered with daily activities or work as a result of emotional health.No problems with work or other daily activities as a result of emotional problems.
Mental healthMHDegree of nervousness or depression.Feels peaceful, happy, and calm all the time.
Meaning of very high scoreMeaning of very low score
Physical component scorePCSNo physical limitations, disabilities, or decrements in well being; high energy level; health relates excellent.Substantial limitations in self-care, physical, social, and role activities; severe bodily pain; frequent tiredness; health relates poor.
Mental component scoreMCSFrequent positive affect; absence of psychological distress and limitations in usual social/role activities due to emotional problems; health rated “excellent.”Frequent psychological distress, substantial social and role disability due to emotional problems; health in general rated “poor.”

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 Supported in part by the Harold and June Geneen Vascular Research Fund.

 Competition of interest: none.

 Additional material for this article may be found online at www.jvascsurg.org.

PII: S0741-5214(08)00775-1

doi:10.1016/j.jvs.2008.05.018

Journal of Vascular Surgery
Volume 48, Issue 4 , Pages 828-835.e1, October 2008

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