Document Detail


Evolution of operative strategies in open thoracoabdominal aneurysm repair.
MedLine Citation:
PMID:  21315544     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
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.
Authors:
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:
Type:  Journal Article; Research Support, Non-U.S. Gov't     Date:  2011-02-11
Journal Detail:
Title:  Journal of vascular surgery     Volume:  53     ISSN:  1097-6809     ISO Abbreviation:  J. Vasc. Surg.     Publication Date:  2011 May 
Date Detail:
Created Date:  2011-05-17     Completed Date:  2011-07-18     Revised Date:  2012-10-03    
Medline Journal Info:
Nlm Unique ID:  8407742     Medline TA:  J Vasc Surg     Country:  United States    
Other Details:
Languages:  eng     Pagination:  1195-1201.e1     Citation Subset:  IM    
Copyright Information:
Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.
Affiliation:
Division of Vascular and Endovascular Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA. mconrad@partners.org
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MeSH Terms
Descriptor/Qualifier:
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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