| Evolution of operative strategies in open thoracoabdominal aneurysm repair. | |
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MedLine Citation:
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PMID: 21315544 Owner: NLM Status: MEDLINE |
Abstract/OtherAbstract:
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OBJECTIVE: During a 24-year interval, we managed >90% of thoracoabdominal aortic aneurysm (TAA) repairs with a clamp-and-sew (clamp/sew) approach supplemented with protective adjuncts, including renal hypothermia and epidural cooling with aggressive intercostal reconstruction for spinal cord protection. A finite paraplegia rate led to operative modifications using distal aortic perfusion (DAP) through atriofemoral bypass to support cord collateral circulation and selective intercostal reconstruction based on motor evoked potential (MEP) monitoring. This study evaluated the effect of DAP/MEP on perioperative outcomes. METHODS: Consecutive patients undergoing repair of nonruptured Crawford extent I-III TAA using DAP/MEP were compared with propensity-matched patients treated with the clamp/sew technique. Outcomes included 30-day mortality and paraplegia. RESULTS: There were 52 patients in the DAP cohort vs 127 undergoing clamp/sew. The DAP and clamp/sew cohorts differed in age (62.6 vs 69.5 years, P = .0003), presence of Marfan disease (10% vs 2%, P = .01), and chronic dissection (37% vs 8%, P = .001). Operative mortality was low (DAP, 2%; clamp/sew, 5%; P = .38). Postoperative renal insufficiency, although doubled in clamp/sew (17%) vs DAP (8%; P = .10), was not significant. DAP patients had a significantly lower incidence of intercostal reconstruction than the clamp/sew group (10% vs 34%, P < .0001), yet there was no paraplegia in the DAP cohort vs 5% in clamp/sew (P = .11). The composite death/paraplegia rate was decreased with DAP at 1 of 52 (2%) vs clamp/sew at 11 of 127 (9%; P = .01). Paraparesis with complete recovery occurred in 5 of 52 (10%) of the DAP group. CONCLUSIONS: Elective TAA repair was accomplished with a low mortality in the DAP and clamp/sew cohorts. The use of MEP in the DAP cohort (despite a higher spinal cord ischemic risk due to the number of chronic dissection patients) decreased the need for intercostal reconstruction, with no paraplegia to date. DAP with MEP is the preferred operative strategy for extent I to III TAA repair. |
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Authors:
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Mark F Conrad; Emel A Ergul; Virendra I Patel; Matthew R Cambria; Glenn M Lamuraglia; Mirela Simon; Richard P Cambria |
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Publication Detail:
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Type: Journal Article; Research Support, Non-U.S. Gov't Date: 2011-02-11 |
Journal Detail:
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Title: Journal of vascular surgery Volume: 53 ISSN: 1097-6809 ISO Abbreviation: J. Vasc. Surg. Publication Date: 2011 May |
Date Detail:
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Created Date: 2011-05-17 Completed Date: 2011-07-18 Revised Date: 2012-10-03 |
Medline Journal Info:
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Nlm Unique ID: 8407742 Medline TA: J Vasc Surg Country: United States |
Other Details:
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Languages: eng Pagination: 1195-1201.e1 Citation Subset: IM |
Copyright Information:
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Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved. |
Affiliation:
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Division of Vascular and Endovascular Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA. mconrad@partners.org |
Export Citation:
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| MeSH Terms | |
Descriptor/Qualifier:
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Aged Aortic Aneurysm, Thoracic / mortality, physiopathology, surgery* Boston Chi-Square Distribution Collateral Circulation Constriction Evoked Potentials, Motor Female Humans Kaplan-Meier Estimate Logistic Models Male Middle Aged Monitoring, Intraoperative* / methods Paraparesis / etiology, prevention & control Paraplegia / etiology, prevention & control Perfusion* Renal Insufficiency / etiology, prevention & control Risk Assessment Risk Factors Spinal Cord Ischemia / etiology, physiopathology, prevention & control* Suture Techniques Time Factors Treatment Outcome Vascular Surgical Procedures* / adverse effects, mortality |
From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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