Distal aortic perfusion and cerebrospinal fluid drainage for thoracoabdominal and descending thoracic aortic repair: ten years of organ protection

Abstract

Objective: To report the long-term results of our experience using cerebrospinal fluid drainage and distal aortic perfusion in descending thoracic and thoracoabdominal aortic repair.

Summary background data: Repair of thoracoabdominal and thoracic aortic aneurysm by the traditional clamp-and-go technique results in a massive ischemic insult to several major organ systems. Ten years ago, we began to use distal aortic perfusion and cerebrospinal fluid drainage (adjunct) to reduce end-organ ischemia.

Methods: Between January 1991 and February 2003, we performed 1004 thoracoabdominal or descending thoracic repairs. Adjunct was used in 741 (74%) of 1004. Multivariable data were analyzed by Cox regression. Number needed to treat was calculated as the reciprocal of the risk difference.

Results: Immediate neurologic deficit was 18 (2.4%) of 741 with adjunct and 18 (6.8%) of 263 without (P < 0.0009). In high-risk extent II aneurysms, the numbers were 11 (6.6%) of 167 with adjunct, and 11 (29%) of 38 without. Long-term survival was improved with adjunct (P < 0.002). The long-term survival results persisted after adjustment for age, extent II aneurysm, and preoperative renal function.

Conclusion: Use of adjunct over a long period of time has produced favorable results; approximately 1 neurologic deficit saved for every 20 uses of adjunct overall. In extent II aneurysms, where the effect is greatest, this increases to 1 saved per 5 uses. Adjunct is also associated with long-term survival, which is consistent with mitigation of ischemic end-organ injury. These long-term results indicate that cerebrospinal fluid drainage and distal aortic perfusion are safe and effective adjunct for reducing morbidity and mortality following thoracic and thoracoabdominal aortic repair.

FIGURE 1. Normal thoracoabdominal aorta and aneurysm classification. Extent I, distal to the left subclavian artery to above the renal arteries. Extent II, distal to the left subclavian artery to below the renal arteries. Extent III, from the sixth intercostal space to below the renal arteries. Extent IV, from the twelfth intercostal space to below the renal arteries (total abdominal aortic aneurysm). Extent V, below the sixth intercostal space to just above the renal arteries.

FIGURE 2. Cerebrospinal fluid drainage.

FIGURE 3. Illustration of distal aortic perfusion circuit.

FIGURE 4. A, 4B: Artist’s illustration and computed tomography scans of a descending thoracic aortic aneurysm that developed into a extent II thoracoabdominal aortic aneurysm after first graft replacement (A) and second graft replacement (B) with reattachment of lower intercostal arteries and reimplantation of the celiac axis, superior mesenteric, right and left renal arteries via separate interposition bypass grafts in a Marfan patient.

FIGURE 5. (A-G) Kaplan-Meier actuarial plots showing the effect of selected risk factors on 10-year survival. Time in years on y-axis. H.R. = hazard ratio.

FIGURE 6. Kaplan-Meier actuarial plots showing the effect of adjuncts on 10-year survival in extent II (A) and nonextent II patients (B). Time in years on y-axis.