Outcomes following Management of Complex Thoracoabdominal Aneurysm by an Open Approach

Abstract

Background: In the last decade, advances in surgical techniques, and the introduction of adjuncts for organ protection, have modified the approach for thoracoabdominal aortic aneurysm (TAAA) surgical repair. The aim of this study is to determine whether the contemporary approach influenced the outcomes.

Methods: From 1989 to 2022, patients who had received elective open surgical repair (OSR) for TAAA at our institution were retrospectively analyzed. This series has been divided in two groups: Group 1 (1989-2009), and Group 2 (2010-2022). Patients included in Group 1 were those treated with a selective use of adjuncts, and Group 2 included patients treated with the systematic use of adjuncts.

Results: A total of 1107 patients were treated (Group 1: 455; Group 2: 652). The surgical management was significantly different between the two groups. The in-hospital mortality was significantly different between the two groups (Group 1: 13.4%, Group 2: 8.1%; p 0.004), as was the rate of permanent spinal cord ischemia (Group 1: 11.9%, Group 2: 7.8%; p 0.023). Renal and respiratory failure were reduced in Group 2, but not significantly.

Conclusions: The use of the adjuncts enabled the achievement of improvement in mortality and SCI prevention in TAAA OSR. Although a refined surgical technique, mortality and morbidity are still noteworthy in this complex aortic field.

Keywords: TAAA; aorta; open surgical repair; thoracoabdominal aortic aneurysm.

Figure 1

(A) Final reconstruction after extent II TAAA OSR with a tube graft. Visceral and renal vessels have been reattached by means of a Carrel patch (a single aortic island with the inclusion of visceral and renal ostia). (B) Final reconstruction after extent II TAAA OSR with a branched graft. Visceral and renal vessels have been reattached by means of selective bypasses.

Figure 2

Graphical summary of the different adjuncts introduced in our clinical practice, and their time of introduction. Figure legend: red color stands for no use of the adjuncts; blue color stands for the use of the adjuncts. For CSFD, red color stands for no use of CSFD; light blue stands for the use of dripping chamber-based systems; blue color stands for the use of the Liquoguard.

Figure 3

(A) Catheterization and perfusion of the left renal artery with an occlusion–perfusion Pruitt catheter; the left kidney was perfused with the HTK solution. (B) In order to reduce the size of the Carrel patch, the left renal artery was divided from the aorta and reattached by means of a selective bypass from the aortic graft. In this picture is also possible to recognize a selective bypass for intercostal arteries.

Figure 4

Intercostal artery reattachment with three different techniques. (A) An aortic island including the origin of several intercostal arteries is reattached to a fenestration created on the aortic graft. (B) Intercostal arteries are reattached selectively to the graft via 6/8 mm interposition grafts. (C) Another possible way to reattach critical intercostal arteries is represented by the “loop graft”. A 14/16 mm graft is anastomosed proximally and distally to the aortic graft. A fenestration is created in this loop graft to reattach the origin of multiple intercostal arteries (dotted circle).