Neurologic Outcomes of Proximal vs Distal Aortic Clamping in Open Thoracoabdominal Aortic Aneurysm Repair

This study aimed to evaluate the impact of proximal vs distal aortic clamping during thoracoabdominal aortic aneurysm (TAAA) repair, with a focus on the incidence and predictors of left recurrent laryngeal nerve (LRN) injury, and by assessing associations with respiratory morbidity, neurologic complications, and long-term survival.

A retrospective analysis was performed on 555 patients who underwent open Crawford extent I or II TAAA repair between 1997 and 2025. Patients were stratified by clamp location relative to the left subclavian artery. Operative data, early outcomes, and long-term survival were compared. Multivariable logistic regression was used to identify predictors of LRN injury and respiratory complications.

Of the 555 patients, 142 (25.6%) underwent Crawford extent II repairs. Patients who had proximal clamps were younger and more likely male, and they had higher rates of previous sternotomy. They required more frequent left subclavian artery bypass, had longer clamp times, and had more frequent use of partial bypass and intercostal artery reimplantation. The overall LRN injury rate was 26 of 555 patients (4.7%), significantly higher in the proximal clamp group (odds ratio [OR], 4.68; 95% CI, 2.00-11.43; P < .001). Chronic obstructive pulmonary disease was also an independent predictor (OR, 3.48; 95% CI, 1.38-9.07; P = .009). LRN injury was not associated with increased respiratory complications (OR, 1.01; 95% CI, 0.59-1.69; P = .977). Operative mortality, neurologic deficit, and spinal cord ischemia rates were similar between the groups. Long-term survival at 10 years was 88.0%, with no significant difference between the clamp groups.

Proximal aortic clamping during TAAA repair is associated with a higher risk of LRN injury, but it does not increase respiratory morbidity or neurologic complications or affect long-term survival.