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28-Year Experience with Ruptured and Symptomatic Type I-III Thoracoabdominal Aortic Aneurysms at a Large Tertiary Referral Center



Objectives:

Given the relative rarity of ruptured and symptomatic type I-III thoracoabdominal aortic aneurysms (TAAA), data is scarce regarding of the outcomes of those who survive to repair. The goal of this study was to determine short and long-term outcomes after open repair of type I-III TAAA surgery for ruptured and symptomatic TAAA and compare the results to elective TAAA repairs.


Methods:

All open type I-III TAAA repairs performed from 1987-2015 were evaluated using an institutional database. Charts were retrospectively evaluated for peri-operative outcomes: major adverse event (MAE), in-hospital death, spinal cord ischemia (SCI) and long-term survival. Univariate analysis was performed using the Fisher’s exact test for categorical variables and ANOVA for continuous variables. Logistic regression was used for in-hospital endpoints; survival analysis was performed with Cox proportional hazards modelling and Kaplan-Meier techniques.


Results:

Five hundred-sixteen patients had an open type I-III TAAA repair during the study period. Fifty-nine (11.4%) were performed for rupture and 51 (9.9%) were performed for symptomatic aneurysm. Ruptured and symptomatic groups were more likely to be older, female and have larger presenting aortic diameters. Most of the ruptured and symptomatic cases were transferred from an outside facility (59.3% and 54.9%, respectively). Intraoperatively, the elective cohort was more likely to receive left-heart bypass as an operative adjunct; ruptures were less likely to receive a renal bypass and operative time was highest for the elective cohort. Perioperative mortality was 18.6% for ruptured, 2.0% for symptomatic, and 7.4% for elective indications. Ruptures were most likely to require new hemodialysis after repair (20.3% versus 10.3% for elective, p=.02). On adjusted analysis, ruptures were more likely to suffer from perioperative death (AOR: 4.5, 95% CI: 1.7-11.4) and major adverse events (AOR: 2.8, 95% CI: 1.4-5.4). Ruptured and symptomatic aneurysms were not independently associated with spinal cord ischemia, however pre-operative hemodynamic instability was predictive (AOR: 8.7, 95% CI: 1.7-44.2). Both rupture and symptomatic cases were associated with decreased survival on Kaplan-Meier analysis with five-year survival for ruptures at 35%, symptomatic at 47.7% and elective at 63.7%, p<.001. Adjusted hazards of death were 1.2 (95% CI: 0.9-1.8) in the symptomatic cohort and 2.3 (95% CI: 1.5-3.7) in the ruptured cohort.


Conclusion:

Open ruptured and symptomatic type I-III TAAA repairs can be performed with acceptable morbidity and mortality. Most symptomatic and rupture repairs were performed after transfer from another institution. Post-operative spinal cord ischemia is most strongly related to the pre-operative hemodynamic status of the patient.



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