Open thoracoabdominal aortic aneurysm repair in the modern era: results from a 20-year single-centre experience

Abstract

Objectives: The efficacy and durability of actual treatments (open, endovascular and hybrid) for thoracoabdominal aortic aneurysm (TAAA) repair are not yet completely defined. Open surgical repair using a multi-adjunct (ADJ) approach has been the standard of care for many years and may still be an effective treatment option. This study aimed to assess the outcomes of open TAAA repair since the introduction of the available ADJ.

Methods: From 1994 to 2014, 542 consecutive patients underwent open TAAA repair in our institution, routinely receiving aortic distal perfusion and the other ADJ (either for visceral and spinal cord protection). The aetiology of TAAA was identified to be degenerative in 325 (60%) patients and chronic post-dissection in 160 (29.5%) patients. Other causes such as connective tissue disorders, vasculitis and infective aneurysms were less represented (10.5%). Extensive type I and II repair was required in 128 (23.6%) and 285 (52.6%) patients, respectively. All patients were followed up at 3 and 6 months after surgery and yearly thereafter using computed tomography angiogram.

Results: The overall 30-day mortality and paraplegia rates were 8.5 and 4.2%, respectively. Age [odds ratio (OR) 1.07 per year, 95% confidence interval (CI) 1.02-1.13], female gender (OR 2.52, 95% CI 1.27-4.99), urgency (OR 2.78, 95% CI 1.12-6.20) and emergency (OR 3.81, 95% CI 1.00-11.50) emerged as independent risk factors for 30-day mortality. Follow-up was 100% complete (mean 6.32 years). Overall 1-, 5- and 10-year survival was 85.9 ± 1.5, 74.2 ± 2.0 and 61.6 ± 2.5%, respectively. The extent of surgical repair did not significantly influence late hospital death (P = 0.56). For patients surviving the first 30 days, a degenerative aneurysm aetiology negatively impaired long-term survival compared with the other diseases [hazard ratio = 1.66; 95% CI (1.13-2.44)]. Five- and 10-year freedom from reoperation was 86.3 ± 1.8 and 80.7 ± 2.3%, respectively, and 8.5% of patients required aortic reinterventions.

Conclusions: In elective cases, open TAAA repair has to be considered an effective option associated with low necessity of reoperation at follow-up. The extent of aortic resection did not affect long-term mortality. Conversely, survival was mainly determined by patient age and preoperative condition.

Keywords: Aneurysm; Endovascular aortic repair; Spinal cord ischaemia; Thoracoabdominal aortic aneurysm.