Late aortic and graft-related events after thoracoabdominal aneurysm repair

Unlike abdominal aortic aneurysm repair, little information exists regarding aortic-related morbidity (synchronous/metachronous aneurysm or graft-related complications) after thoracoabdominal aneurysm (TAA) repair. This study was performed to define such events and identify factors related to their development.

Over a 15-year interval, 333 patients underwent TAA repair (type I, n = 90; 27%; type II, n = 59; 18%; type III, n = 118; 35%; and type IV, n = 66; 20%). Late aortic events were defined as aortic disease causing death or necessitating further intervention or graft-related complications (infection, pseudoaneurysm, branch occlusion) after hospital discharge. Variables were assessed for their association with aortic events with Cox proportional hazards regression.

In-hospital mortality occurred in 28 patients (8.4%), which left 305 available for follow-up (mean length of follow-up, 26 months; interquartile range, 2.7 to 38.4 months). After TAA repair, aneurysm remained in 60 patients (19.7%; ascending/arch, n = 41; 68.3%; discontinuous infrarenal, n = 12; 20%; contiguous descending, n = 7; 11.7%; contiguous abdominal, n = 4; 6.7%). Events occurred in 33 individuals (10.8%) at 30 +/- 27 months after surgery. Twenty-four patients (73% of events; 7.9% of cohort) had aortic-related events, including another elective aneurysm repair (n = 16), urgent/emergent aneurysm operation (n = 5), acute dissection (n = 2), and atherothrombotic embolization (n = 1). Nine patients (27% of events; 2.9% of cohort) had graft-related incidents, including renovisceral occlusion (n = 5), visceral patch pseudoaneurysm (n = 2), graft infection (n = 2), and graft-esophageal fistula (n = 1). Variables independently predictive of events were female gender (odds ratio [OR], 2.3; P =.03), initial aneurysm rupture (OR, 4.8; P =.04), partial disease resection (OR, 4.2; P =.0008), and expansion of remaining aortic segments on imaging surveillance (OR, 2.5; P =.03). The event-free survival rates were 96% (95% CI, 93% to 98%) and 71% (95% CI, 60% to 83%) at 1 and 5 years.

Late aortic events occur in at least 10% of patients after TAA repair and are usually the result of native aortic disease in remote (or noncontiguous) aortic segments. Graft-related complications, in particular, degeneration of inclusion anastamoses, are rare. Female gender, original presentation with rupture, and unresected disease identify those at highest risk. These findings verify the anatomic durability of TAA repair and suggest indefinite aortic surveillance is indicated for those at risk of events.