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Thoracoabdominal aortic aneurysm repair after prior aortic surgery
Joseph V Lombardi1, Jeffrey P Carpenter, Alberto Pochettino
1Department of Surgery, University of Pennsylvania School of Medicine, University Hospital, 4 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104, USA.
Purpose:
The purpose of this study was to determine whether the morbidity and mortality of surgery for thoracoabdominal aortic aneurysm (TAAA) in patients with prior aortic surgery are increased.
Methods:
The results for all patients undergoing operation for TAAA at a single institution were reviewed.
Results:
Over a 10-year interval, 279 patients (136 women and 143 men) underwent aortic replacement for TAAA. The mean patient age was 68 years (range, 34-90). The extent of aortic replacement was relatively evenly distributed: type I (91), type II (54), type III (78), or type IV (56). Of these 279 patients, 76 (27%) had undergone prior aortic surgery. Prior infrarenal AAA was the most common prior procedure (56, 20%). Reoperation for prior failed TAAA repair was performed in 20 (7%) patients. A history of Marfan syndrome was highly associated with the need for remedial TAAA procedures (P <.0001). Overall 30-day mortality was 11.4% (32). Mortality was independent of prior aortic surgery (P =.98), prior AAA (P =.84), prior TAAA (P =.61), and gender (P =.18). Postoperative complications were seen in 67 (24%) patients and were more likely in patients who had undergone prior AAA surgery (P =.008). TAAA repair in patients with recurrent TAAA was not associated with higher morbidity (P =.33). Paraplegia (10) occurred in type I (3), type II (2), and type III (5) aneurysms but not in type IV (0), and its development was associated with higher mortality (P =.01). Prior aortic surgery was not found to be predictive of paraplegia (P =.90), although 30% of patients who developed paraplegia had a history of prior AAA repair.
Conclusions:
Aortic reoperation for TAAA is required in a significant number of patients, particularly those with Marfan syndrome. Therefore, ongoing surveillance of the residual aorta is mandatory. Postoperative complications are more likely to occur in patients after prior infrarenal aortic replacement, but mortality is not significantly increased. Special technical considerations exist for remedial procedures after failed TAAA repair to provide protection for the spinal cord, kidneys, and viscera. Patients with failed TAAA procedures or progression of aneurysmal extent should be offered reoperation when indicated.