Open reconstruction of thoracoabdominal aortic aneurysms

Technical details of our strategy for reconstructing the thoracoabdominal aorta are presented. Between October 1999 and June 2012, 152 patients underwent surgery for thoracoabdominal aortic aneurysms (Crawford classification type I =21, type II =43, type III =73, type IV =15). Mean age was 64.6±13.9 years. Sixty-three (41.4%) patients had aortic dissection, including acute type B dissection in 2 (1.2%) and ruptured aneurysms in 17 (11.2%). Eight (5.3%) patients had mycotic aneurysms, and 3 (2.0%) had aortitis. Emergent or urgent surgery was performed in 25 (16.4%) patients. Preoperative computed tomography (CT) scan or magnetic resonance (MR) angiography detected the Adamkiewicz artery in 103 (67.8%) patients. Cerebrospinal fluid drainage (CSFD) was performed in 115 (75.7%) patients and intraoperative motor evoked potentials were recorded in 97 (63.8%). One hundred and seven (70.4%) patients had reconstruction of the intercostal arteries from T7 to L2, 35 of which were reconstructed with the aortic patch technique and 72 with branched grafts. The mean number of reconstructed intercostal arteries was 3.1±2.5 pairs. Mild hypothermic partial cardiopulmonary bypass at 32-34 °C was used in 105 (69.1%) patients, left heart bypass was used in 4 (2.6%), and deep hypothermic cardiopulmonary bypass below 20 °C was used in 42 (27.6%). Thirty-day mortality was 9 (5.9%), and hospital mortality was 20 (13.2%). Independent risk factors for hospital mortality were emergency surgery (OR 13.4, P=0.003) and aortic cross clamping over 2 hours (OR 5.7, P=0.04). Postoperative spinal cord ischemia occurred in 16 (10.5%, 8 patients with paraplegia and 8 with paraparesis). Risk factors for developing spinal cord ischemic complications were prior surgery involving either the descending thoracic or the abdominal aorta (OR 3.75, P=0.05), diabetes mellitus (OR 5.49, P=0.03), and post-bypass hypotension <80 mmHg (OR 1.06, P=0.03). Postoperative survival at 5 years was 83.6±4.5%; 5-year survival was 47.5±8.6% in patients with spinal cord ischemia and 88.9±10.4% in those without spinal cord ischemia.