Initial Experience Using A Dedicated Multidisciplinary Team For Open Repair Of Descending Thoracic And Thoracoabdominal Aortic Aneurysms
Aamir Shah, MD, Cassra Arbabi, MD, Dominick Megna, MD, NavYash Gupta, MD, Nicola D'Attellis, MD, Jeffrey Chung, MD, FAAN, Bruce Gewertz, MD, Ali Azizzadeh, MD.
Cedars-Sinai Medical Center, Los Angeles, CA, USA.
OBJECTIVES: Management of complex aortic aneurysms that are not suitable for endovascular repair remains a challenge. We report our experience using a dedicated multidisciplinary team for open repair of descending thoracic and thoracoabdominal aortic aneurysms (DTAA & TAAA) at a single quaternary care institution.
METHODS: A retrospective review of an institutional database was performed. All patients undergoing repair of DTAA and TAAA were treated by a multidisciplinary team consisting of vascular and cardiac surgery, cardiovascular anesthesia/critical care and neurology. Primary outcomes included in-hospital mortality, stroke, visceral ischemia and paraplegia.
RESULTS: We treated 21 consecutive patients (mean age 58.9 +/- 18.9 years, 62% male) for DTAA (n=7), and TAAA (n=14) from August 2017 to July 2020. Co-morbidities included: hypertension 86%, diabetes mellitus 9.5%, cerebrovascular disease 19%, coronary artery disease 19%, and chronic kidney disease 24% with 4.7% requiring dialysis. Connective tissue disorders were present in 33% of patients, 48% had a chronic aortic dissection and 71% had prior aortic surgery. Circulatory support to achieve distal aortic perfusion was used in 90% (n=19) of patients with left-heart bypass in 52%, and cardiopulmonary bypass (CPB) in 38% (with hypothermic circulatory arrest in 33%). Spinal cord protection strategies included systemic hypothermia, cerebrospinal fluid drainage in 62%, and intercostal arteries re-implantation in 14% as guided by motor (MEP) and somatosensory evoked potentials (SSEP). In-hospital mortality was 4.7% (n =1); this single death was from visceral ischemia. There were no strokes, permanent paraplegia, or surgical site infections. Complications included re-operation for bleeding in 4.7% (n=1) and new renal replacement therapy in 9.5% (n=2) with one patient (4.7%) requiring dialysis at discharge.
CONCLUSIONS: Our initial experience using a dedicated multidisciplinary approach to open repair compares favorably to published results from major aortic centers with larger caseloads. As the total number of open cases will likely continue to decline, a similar regimented and collaborative strategy should be employed to optimize results.
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