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Identifying TAAA IV Patients at High Risk for Open Repair
Sapan S. Desai, MD, PhD, MBA, Kristofer Charlton-Ouw, MD, Harleen K. Sandhu, MD, Charles C. Miller, III, PhD, Ali Azizzadeh, MD, Anthony L. Estrera, MD, Hazim J. Safi, MD.
University of Texas Houston Medical School and Memorial Hermann Hospital, Houston, TX, USA.
OBJECTIVES:Open surgical repair for thoracoabdominal aortic aneurysm extent IV (TAAA IV) patients was thought to be low risk for morbidity and mortality, especially when compared to more extensive disease found in other variations (i.e., extent II). The purpose of this paper is to identify patient comorbidities that adversely affect survival in open repair for TAAA IV and to identify candidates suitable for alternative management.
METHODS: We completed a retrospective analysis of a prospectively collected institutional database of TAAA repairs completed between 1991-2010. Over this period, our standard protocol for repair evolved to include the spinal protective adjuncts of distal aortic perfusion, passive moderate hypothermia, and perioperative cerebrospinal fluid drainage. Univariate and multivariate analysis were used to determine the effect of adjuncts and patient comorbidities on perioperative neurologic deficits and death.
RESULTS: We repaired 1,528 TAAA during the study period, including 241 TAAA IV (67% male, mean age of 70). Three of 241 patients (1.2%) suffered neurologic deficits such as paraplegia or paraparesis. In 91 of 241 patients, spinal protective adjuncts were not used and did not significantly affect the rate of neurologic deficits. Overall mortality in patients with preserved preoperative renal function (GFR >60 mL/min/1.73m2) was 10/241 (8.3%). However, the 60 patients in the lowest quartile of renal function (GFR <44 mL/min/1.73m2) had a mortality of 38.3% (OR 6.96, 95% CI 2.43-19.95, p<0.0001).
CONCLUSIONS:Poor preoperative renal function is a statistically significant factor that dramatically influences mortality following open TAAA IV repair. Unlike open repair of other TAAA extents, spinal protective adjuncts did not affect the rate of neurologic deficits. TAAA IV patients with poor renal function may be suitable candidates for less invasive options.
Univariate Analysis| Variable | Total (%) | Deaths (%) | OR | 95% CI | P | | GFR <=43 | 60 (24.9) | 23 (38.3) | 6.96 | 2.43-19.95 | 0.0001 | | GFR 44-60 | 60 (24.9) | 7 (11.7) | 1.48 | 0.44-4.95 | 0.74 | | GFR 61-81 | 60 (24.9) | 5 (8.3) | 1.02 | 0.22-4.69 | 0.98 | | GFR >=82 | 61 (25.3) | 5 (8.2) | 1 | | |
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