Open Repair of Ruptured Descending Thoracic and Thoracoabdominal Aortic Aneurysms in 100 Consecutive Cases Mario F. Gaudino, Christopher Lau, Monica Munjal,

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Open Repair of Ruptured Descending Thoracic and Thoracoabdominal Aortic Aneurysms in 100 Consecutive Cases Mario F. Gaudino, Christopher Lau, Monica Munjal, Leonard N Girardi Department of Cardiothoracic Surgery Weill Cornell Medical College New York-Presbyterian Weill Cornell Medical Center New York, NY

Introduction Ruptured DTA and TAAA represent a very high-risk cohort of patients in need of emergent thoracic aneurysm repair. Hemodynamic instability may limit the application of modern methods of end-organ protection. Previous studies have shown substantially higher rates of mortality and major complications. Endovascular repair has improved short-term outcomes, but reinterventions and suboptimal long-term survival are concerning. We sought to investigate outcomes in a high-volume tertiary aortic referral center.

Ruptured series (n=100) Intact series (n=575) pvalue Age (mean, std. dev.)67.2± ± Male61 (61%)336 (58.4%).63 Smoking94 (94%)423 (73.6%)<.001 Previous coronary revascularization20 (20%)115 (20%)1.0 Hypertension97 (97%)553 (96.2%).686 Chronic pulmonary disease60 (60%)216 (37.6%)<.001 Previous stroke8 (8%)29 (5.1%)<.001 Peripheral vascular disease38 (38%)147 (25.6%).01 Diabetes17 (17%)44 (7.7%).003 Family history of aneurysm1 (1%)30 (5.2%).06 Renal dysfunction59 (59%)147 (25.5%)<.001 Previous cardiac surgery38 (38%)290 (50.4%).09 Preoperative spinal cordinjury Thoracoabdominalaortic aneurysm 7 (7%) 57 (57%) 3 (0.5%)<.001 Extent 1 and2 Descending thoracicaneurysm 48(84.2%) 43 (43%) 309 (75.7%) 167 (29.0%) Aneurysmsize (cm) (mean, std. dev.)7.1±2.06.9± Shock27 (27%)1 (0.2%)<.001 Emergent operation96 (96%)115 (20%)<.001 Data presented as n (%), unless otherwise noted. Ruptured Series DemographicsRuptured versus Intact Series Demographics 408 (70.9%).05

Intraoperative Characteristics Ruptured series (n=100) Intact series (n=575) pvalue Clamp and sew68 (68%)370 (64.3%).40 Circulatory arrest11 (11%)49 (8.5%).42 Partial bypass21 (21%)205 (35.7%).15 Medianpartial bypass time (min) Median DHCA time (min) Median crossclamp time (min) Spinal drainage65 (65%)493 (85.7%)<.001 At least 1 intercostal reimplantation22 (22%)252 (43.8%)<.001 More than 1 intercostalreimplantation11 (11%)132 (22.9%).001 Concomitant procedures35 (35%)173 (30.1%)<.001 Renal perfusion15 (15%)131 (22.8%).21 Data presented as n (%), unless otherwise noted.

Ruptured series (n=100) Intact series (n=575) p value In-Hospital and 30 day mortality14 (14%)24 (4.2%).01 Myocardial infarction7 (7%)5 (0.8%).004 Stroke15 (0.8%).86 Respiratory failure19 (19%)33 (5.7%)<.001 New dialysis11 (11%)24 (4.2%).01 Spinal cord injury5 (5%)14 (2.4%).16 Recurrent nerve lesion9 (9%)38 (6.6%).38 Re-exploration for bleeding2 (2%)14 (2.4%).79 Data presented as n (%), unless otherwise noted. In-hospital Outcomes

Dead (n=14)Alive (n=86)P value Male7 (50)54 (62.8)0.363 Smoking14 (100)80 (93.0)0.308 Previous coronary revascularization3 (21.4)17 (19.8)0.885 Hypertension14 (100)83 (96.5)0.478 Chronic pulmonary disease12 (85.7)48 (55.8)0.034 Previous stroke3 (21.4)5 (5.8)0.046 Peripheral vascular disease9 (64.3)29 (33.7)0.029 Diabetes7 (50.0)10 (11.6)<0.001 Family history of aneurysm0 (0.0)1 (1.2)0.685 Renal dysfunction12 (85.8)47 (54.7)0.028 Previous cardiac surgery6 (42.9)32 (37.2)0.686 Preoperative spinal cord injury3 (21.4)4 (4.7)0.023 Thoracoabdominal aneurysm8 (57.1)49 (57.0)0.991 Extent 1 and 26 (75.0)42 (48.8)0.678 Shock8 (57.1)19 (22.1)0.006 Emergent operation14 (100)82 (95.3)0.410 Univariate analysis for early death (ruptured series) Data presented as n (%), unless otherwise noted.

Preoperative Characteristics in Propensity-Matched Series Ruptured series (n=61) Intact series (n=61) p value Age (mean, std. dev.)66.8± ± Male35 (57.4)33 (54.1).85 Smoking56 (91.8)57 (93.4).72 Previous coronary revascularization11 (18.0)9 (14.8).62 Hypertension58 (95.1)61 (100.0).07 Chronic pulmonary disease37 (60.7) NS Previous stroke3 (4.9).70 Peripheral vascular disease18 (29.5)16 (26.2).68 Diabetes9 (14.8)8 (13.1).79 Family history of aneurysm1 (1.6) NS Renal dysfunction26 (42.5)29 (47.5).95 Previous cardiac surgery20 (32.8)18 (29.5).41 Preoperative spinal cord injury4 (6.6)1 (1.6).17 Extent 1 and 230 (49.2)32 (52.5).89 Aneurysm size (mm) (mean, std. dev.)7.2±2.17.2± Emergent operation57 (93.4) NS Data presented as n (%), unless otherwise noted.

In-hospital Outcomes in Propensity-Matched Series Ruptured series (n=61) Intact series (n=61) p value In-hospital death0 (0)1 (1.6)0.31 Myocardial infarction2 (3.3)0 (0)0.15 Stroke0 (0) 0.60 Respiratory failure12 (19.7)9 (14.8)0.36 New dialysis4 (6.6)6 (9.8)0.30 Spinal cord injury4 (6.5)1 (1.6)0.35 Data presented as n (%), unless otherwise noted.

Freedom from reoperation (Overall population)

Conclusions Open repair of ruptured thoracic aortic aneurysms can be performed with a gratifying rate of salvage. The incidence of respiratory failure, renal failure and myocardial infarction are significantly higher than in patients with intact aneurysm. For patients with similar preoperative comorbidities, perioperative and long-term survival are not affected by the presence of a ruptured aneurysm. Experienced centers may be able to provide the advantage of reduced perioperative mortality and enhanced long-term survival.

Freedom from reoperation (matched population)

Predictors of In-hospital Major Adverse Events in the overall population Dependent VariableVariableOR (95% CI) p value Major postoperative adverse events Female 2.32 ( ).002 Urgent/emergent operation 2.65 ( ).002 Renal Status: Hemodialysis 4.54 ( ).009 Ruptured aneurysm 1.78 ( ).27 OR, odds ratio; CI, confidence interval.