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A Quarter Century of Organ Protection in Open Thoracoabdominal Repair
Anthony L Estrera*, Harleen K Sandhu*, Kristofer M Charlton-Ouw*, Rana O Afifi*, Ali Azizzadeh*, Charles C Miller, III*, Hazim J Safi
University of Texas Health Science Center at Houston, HOUSTON, TX

OBJECTIVE(S):
Thoracoabdominal aortic aneurysm (TAAA) remains a challenging problem. We describe our experience with open TAAA and descending thoracic (DTAA) aortic aneurysm repair.
METHODS:
Between 1991 and 2014, we repaired 1904 DTAA or TAAA in 1815 patients. Mean age was 64.5±13.6 with 680/1815 (37.5%) women. Of 1904 operations, 664 (35%) were DTAA, 312 (16%) TAAA1, 308 (16%) TAAA2, 186 (9%) TAAA3, 341 (18%) TAAA4, and 111 (6%) TAAA5. 229 (12%) were redo procedures. Adjunct (cerebrospinal fluid drainage+distal aortic perfusion) was used in 75%.
RESULTS:
653/1904 (34%) had aortic dissection and 141 (7.4%) had rupture. Preoperative glomerular filtration rate (GFR) was 67 ml/min/1.73m2 (interquartile range (IQR) 48-95). Renal failure requiring dialysis occurred in 316 (16.6%). Immediate neurological-deficit (ND) occurred in 89 (4.7%) and delayed in 105 (5.5%). Of these, 47/194 (24.2%) recovered by the time of discharge. Postoperative stroke was 90/1904 (4.7%). 30-day mortality was 261/1904 (13.7%). Mortality with GFR >95 was 25/459 (5.45%), and 112/427 (26.2%) with GFR <48 (p<0.0001). In multivariable analysis, immediate ND was greater in females (p<0.02) and TAAA2 or 3 (p<0.0001); it was significantly reduced by higher GFR (p<0.0001) and use of adjunct (p<0.02), particularly in TAAA2 or 3 (interaction p<0.0016). Adjunct is the only significant predictor of recovery after ND (p<0.035). Predictors of 30-day mortality were age (p<0.02), GFR (p<0.0001), TAAA2 (p<0.03), TAAA3 (p<0.002), and emergency (p<0.0001).
CONCLUSIONS:
Open thoracoabdominal repair demonstrates acceptable mortality and morbidity and provides a benchmark for endovascular repair. Adjunct is protective against ND in TAAA2 and 3, and improves recovery.


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