Impact of shaggy aorta on outcomes of open thoracoabdominal aortic aneurysm repair

2514 Cases of Thoracoabdominal and Descending Thoracic Aorta Surgery: Strategies Associated With Improved Survival, Stroke, and Paraplegia

BACKGROUND

Despite the remarkable outcome of open thoracoabdominal aortic repairs of high-volume aortic centers, generalized results that span diverse clinical settings are needed in the era of thoracic endovascular aortic repair. This study explored national real-world data focusing on the impact of cumulative surgical volume on the operative outcomes.

METHOD

Data from the Korean National Health Insurance Service claims database were used to create a cohort that included adult patients who underwent open thoracoabdominal or descending thoracic aortic aneurysm repairs from 2008 to 2020. The primary outcome was operative mortality defined as 30-day mortality or in-hospital mortality. The secondary outcome was adverse early outcome defined as a composite measure of operative mortality, stroke, and spinal cord injury.

RESULTS

The study included 2514 patients (mean age, 60.7 years; 615 women [24.5%]). Distribution of cases revealed a pronounced bias toward a limited number of larger centers: 1724 operations (68.6%) were concentrated in 6 highest-volume centers. Operative mortality rates decreased with increasing surgical volume: 30.1% in institutions with <50 cases, 20.6% for 50 to 99, 15.0% for 100 to 299, and 10.5% for those with ≥300 cases (P < .001). Multivariable analyses further revealed that higher hospital volume was associated with lower risks of operative mortality and adverse early outcomes.

CONCLUSIONS

The early operative outcomes of open thoracoabdominal aortic aneurysm repairs were significantly influenced by the institutional volume of the operating centers, highlighting the indispensable role of experience and expertise. This suggests the strategic aggregation of cases toward specialized, high-volume centers to optimize surgical results.

Moderate hypothermic circulatory arrest with antegrade cerebral perfusion for the open repair of juxtarenal abdominal aortic aneurysm repair with shaggy aorta

Shaggy aorta is severe luminal surface degeneration of the aorta leading to an increased risk of plaque destabilization and embolization to the peripheral or visceral vessel beds. It represents a challenging clinical entity for both endovascular and open repair owing to potential atheroembolization, increased early morbidity and mortality, and poor long-term survival. Patients may be denied repair owing to its high risks. Herein, we present a novel approach to open repair of a juxtarenal abdominal aortic aneurysm with shaggy aorta using moderate hypothermic circulatory arrest with antegrade cerebral perfusion and concurrent flow modification to mitigate the risk of atheroma embolism.

Clinical Outcomes of Patients With Cholesterol Crystal Embolism Accompanied by Lower Extremity Wound

Cholesterol crystal embolism (CCE) accompanied by a lower extremity wound is occasionally difficult to differentiate from chronic limb-threatening ischemia (CLTI) and treat. The present multi-center retrospective observational study investigated the clinical characteristics and prognosis of CCE with lower extremity wounds. Consecutive patients (n = 58) clinically diagnosed as CCE with lower extremity wounds between April 2010 and December 2019 were studied. CCE was diagnosed using histological findings, foot condition, renal impairment, and eosinophilia. The primary outcome was 1-year wound healing rate. Patients with CCE were compared with 1309 patients diagnosed with CLTI with tissue loss during the same study period. The CCE group had a significantly more severe Wound, Ischemia, and foot Infection (WIfI) classification compared with the CLTI group. After Kaplan-Meier analysis, the CCE group had a similar 1-year wound healing (55.1 vs 58.3%, P = .096) as the CLTI group. In multivariate stratified Cox regression analysis by WIfI stages, CCE was significantly associated with poor wound healing compared with CLTI [hazard ratio .36 (95% confidence interval .21-.62)]. In conclusion, among the similar WIfI clinical stages, wound healing was significantly worse in the CCE group than in the CLTI group.

Predicting operative mortality in patients who undergo elective open thoracoabdominal aortic aneurysm repair

Background

We have developed a model aimed at identifying preoperative predictors of operative mortality in patients who undergo elective, open thoracoabdominal aortic aneurysm (TAAA) repair. We converted this model into an intuitive nomogram to aid preoperative counseling.

Methods

We retrospectively analyzed data from 2884 elective, open TAAA repairs performed between 1986 and 2023 in a single practice. Using clinical and selected operative variables, we built 4 predictive models: multivariable logistic regression (MLR), random forest, support vector machine, and gradient boosting machine. Each model's predictive effectiveness was evaluated with the C-statistic. Test C-statistics were computed using an 80:20 cross-validation scheme with 1000 iterations.

Results

Operative death occurred in 200 patients (6.9%). Test set C-statistics showed that the MLR model (median, 0.68; interquartile range [IQR], 0.65-0.71) outperformed the machine learning models (0.61 [IQR, 0.59-0.64] for random forest; 0.61 [IQR, 0.58-0.64] for support vector machine; 0.65 [IQR, 0.62-0.67] for gradient boosting machine). The final MLR model was based on 7 characteristics: increasing age (odds ratio [OR], 1.04/y; P < .001), cerebrovascular disease (OR, 1.54; P = .01), chronic kidney disease (OR, 1.53; P = .008), symptomatic aneurysm (OR, 1.42; P = .02), and Crawford extent I (OR, 0.66; P = .08), extent II (OR, 1.61; P = .01), and extent IV (OR, 0.41; P = .002). We converted this model into a nomogram.

Conclusions

Using institutional data, we evaluated several models to predict operative mortality in elective TAAA repair, using information available to surgeons preoperatively. We then converted the best predictive model, the MLR model, into an intuitive nomogram to aid patient counseling.

Spinal Cord Injury Risk in Open Repair for Descending Thoracic and Thoracoabdominal Aneurysm

Objective: In open repair for descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA), the influence of re-interventions on spinal cord injury (SCI) remains unclear. This study evaluated the relationships between re-interventions, atherosclerosis, and SCI. Methods: We retrospectively reviewed 78 patients who underwent open surgical repair for DTAA or TAAA between April 2011 and May 2023. The associations of SCI with (i) re-interventions with a history of endovascular therapy and graft replacement and (ii) atherosclerotic factors, including monocyte count, triglyceride levels (TG), and intra-aortic plaques, were examined. Results: The rates of SCI complications and 30-day mortality were both 3.8% (3/78). There was no significant difference between the incidence of SCI in the re-intervention and first-time intervention groups (p >0.90). However, patients with protruding plaque on computed tomography (CT) were more affected by SCI than those without (13.3% vs. 1.6%, p = 0.034). Univariate analysis revealed that SCI was associated with increased monocyte count, TG, protruding plaques on CT, and intraoperative blood loss. Conclusion: Re-interventions for DTAA and TAAA showed no association with the development of SCI under appropriate protective measures. The implicated risk factors may be atherosclerosis factors such as elevated monocyte count, TG, and protruding plaques on CT.

Impact of shaggy aorta on intraoperative cerebral embolism during carotid artery stenting

BACKGROUND

Careful selection of patients for carotid stenting is necessary. We suggest that patients with a shaggy aorta syndrome may be at higher risk for perioperative embolic complications.

METHODS

The study is a retrospective subanalysis of the SIBERIA Trial. We included 72 patients undergoing transfemoral carotid artery stenting. Patients were monitored during the procedures using multifrequency transcranial Doppler with embolus detection and differentiation. Pre- and postprocedural (2 and 30 days) cerebral diffusion-weighted cerebral MRIs were performed.

RESULTS

Forty-six patients had shaggy aorta syndrome. Intraoperative embolisms were recorded in 82.6% and 46.1% of patients with and without shaggy aorta syndrome, respectively (P=0.001). New asymptomatic ischemic brain lesions in the postoperative period occurred in 78.3% and in 26.9% of patients with and without shaggy aorta syndrome, respectively (P<0.001). There were no cases of stroke within 2 days in both groups. 3 (6.5%) cases of stroke within 30 days after the procedure were observed only in patients with shaggy aorta syndrome. There were no cases of contralateral stroke. Shaggy aorta syndrome (OR 5.54 [1.83:16.7], P=0.001) and aortic arch ulceration (OR 6.67 [1.19: 37.3], P=0.02) were independently associated with cerebral embolism. Shaggy aorta syndrome (OR 9.77 [3.14-30.37], P<0.001) and aortic arch ulceration (OR 12.9 [2.3: 72.8], P=0.003) were independently associated with ipsilateral new asymptomatic ischemic brain lesions.

CONCLUSIONS

Shaggy aorta syndrome and aortic arch ulceration significantly increase the odds of intraoperative embolism and new asymptomatic ischemic brain lesions. Carotid endarterectomy or transcervical carotid stent should be selected in patients with shaggy aorta syndrome.

The result of prospective evaluation of 3-dimensional printing-aided extensive thoracoabdominal aorta repair

OBJECTIVES

Paraplegia is a distressing complication after open thoracoabdominal aortic aneurysm (TAAA) repair, and revascularization of T8-L2-level segmental arteries is considered pivotal to prevent paraplegia. We employed 3-dimensional (3D) printing to efficiently revascularize segmental/visceral arteries and prospectively evaluated its safety and efficacy.

METHODS

From January 1, 2020, to June 30, 2022, we prospectively enrolled patients of extent I, II, or III TAAA repair. Guidance models were 3D-printed based on preoperative computed tomography, and multibranched aortic grafts were manually constructed upon this model before surgery. The composite outcome of operative mortality, permanent stroke, and permanent spinal cord deficit (SCD) was compared with the historical control group (n = 77, in 2015-2020), subjected to similar TAAA repair without 3D printing.

RESULTS

A total of 38 patients (58.6 ± 13.2 years) underwent open TAAA repair with the aid of 3D printing. Extent I, II, and III repairs were performed in 14 (36.8%), 17 (44.7%), and 7 (18.4%), respectively. Concomitant arch repair and bi-iliac reconstruction were performed in 7 (18.4%) and 6 patients (15.8%), respectively. Mean pump time was 107.7 ± 55.5 minutes. Operative mortality, permanent stroke, and permanent SCD each occurred in 1 patient (2.6%), and the incidence of the composite outcome was 7.9% (3/38). In the control group, mean pump time was 166.0 ± 83.9 minutes, significantly longer than the 3D-printing group (P < .001), and operative mortality, permanent stroke, permanent SCD, and the composite outcome occurred in 7 (9.1%), 9 (11.7%), 8 (10.4%), and 19 (24.7%), respectively.

CONCLUSIONS

Open repairs of extensive TAAA with 3D printing showed favorable safety and efficacy, which need further validation by larger studies.

A comparison of thoracoabdominal aortic aneurysms open repair in patients with or without "shaggy aorta"

OBJECTIVE

In the field of thoracoabdominal aortic aneurysm (TAAA) open surgical repair (OSR), some preoperative characteristics are established risk factors for adverse outcomes, whereas others are supposed to be relevant, but their role still need to be defined; among them, the presence of "shaggy aorta" (SA), an extensive and irregular atheroma within the aorta. The aim of this study is to report the results of a single-center large cohort of patients treated with OSR for TAAA with SA, comparing the outcomes with patients affected by TAAA without SA, and analyzing the impact of the scores for SA on the outcomes.

METHODS

All consecutive patients receiving OSR for TAAA between 2012 and 2021 were retrospectively analyzed. Clinical data from patients with degenerative TAAA were included and analyzed for preoperative characteristics and postoperative outcomes; patients with ruptured TAAA, and patients with aortic dissection were excluded from the analysis. Patients with degenerative aortic aneurysm, thrombus measurement in non-aneurysmal aortic segments (≤40 mm), atheroma thickness ≥5 mm, and finger-like thrombus projection were included in the SA group, whereas the others were included in the non-shaggy aorta group (NSA group). The SA group and NSA group were compared using a propensity-matched comparison. Preoperative computed tomography scans of patients in the SA group were also stratified according to SA grading scores.

RESULTS

A total of 58 patients with SA were identified (male, n = 43 [74.1%], mean age 70.1 ± 7.8 years) among 497 patients with TAAA treated with open surgical repair. After propensity matching, there were 57 patients in the SA group and 57 in the NSA group with correction of all differences in baseline characteristics. Patients in the SA group presented significantly higher in-hospital mortality (SA group, 14.0% vs NSA group, 3.5%; P = .047), postoperative acute renal failure (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease [RIFLE], 3-5) (SA group, 21.1% vs NSA group, 5.3%; P = .013), and postoperative embolization (SA group, 28.1% vs NSA group, 8.8%; P = .008). Spinal cord ischemia and stroke rate were not significantly influenced by the presence of SA. In the SA group, 16 patients (27.6%) with end-organ embolization were compared with 42 patients (72.4%) without a documented embolization considering the grade of aortic "shagginess" and no significant difference was identified (P = .546).

CONCLUSIONS

Despite a better knowledge of the SA disease, new classifications, and intraoperative adjuncts, TAAA patients with SA treated with OSR have worse postoperative outcomes if compared with patients without SA. The presence of SA is a risk factor itself, whereas the grade of "shagginess" seems not to impact on postoperative outcomes.

Thromboembolic complications in transfemoral aortic valve implantation due to aortic wall thrombus and shaggy aorta syndrome

OBJECTIVES

Aortic wall thrombus (AWT) can affect suitability to endovascular repair, while its most aggressive entity is better known as shaggy aorta syndrome. Primary objective was to study the procedural and clinical outcome with regard to atherothrombotic AWT in transfemoral aortic valve implantation.

METHODS

In a retrospective, single-centre analysis, a qualitative 0-10 AWT score classification system was used. The most severely affected aortic area in computed tomography angiography cross-section was assessed for the number of affected segments, thrombus type, thickness, area and circumference. Primary endpoints were 30-day mortality, neurologic, renal and pulmonary events and signs of solid organ infarction.

RESULTS

Between November 2017 and September 2019, 604 patients underwent transfemoral transcatheter aortic valve implantation in our institution. Computed tomography-guided analysis revealed AWT in 11.3% and shaggy aorta syndrome in 6 patients (1.0% with 83.3% male). AWT was mainly present in the descending thoracic and abdominal aorta and was associated with acute renal failure (11.8% vs 3.2%, P ≤ 0.001) and a seven-fold increased rate of disabling peri-interventional stroke (4.4% vs 0.6%, P ≤ 0.001). In all patients with disabling peri-interventional stroke a balloon-expandable prosthesis was used (P ≤ 0.001). In case of shaggy aorta, mortality was more than six-fold increased (2.8% vs 16.7%, P = 0.046).

CONCLUSIONS

Severe and irregular thrombus of the descending thoracic and abdominal aorta has been strongly associated with acute respiratory failure and peri-interventional stroke in transfemoral aortic valve implantation, being more likely using balloon-expandable devices. Our results imply important changes with regard to device design and present international transcatheter aortic valve implantation guidelines.

Total aortic arch replacement using the J-graft open stent graft for distal aortic arch aneurysm: report from two centres in Japan

OBJECTIVES

The open-style stent graft technique has been changing the strategy for true distal arch aneurysms extending to the descending aorta. Our mid-term results of surgical repair using a J-graft open stent graft are presented.

METHODS

Between May 2015 and June 2020, 69 patients with a distal arch aneurysm (53 males, median age 74 years) underwent total arch replacement combined with J-graft open stent deployment. All 59 surviving patients were followed for a median follow-up period of 1.8 (0.6-3.6) years.

RESULTS

Antegrade deployment was successfully performed in all patients without any difficulties. The deployed device was securely fixed at the target area, and it initiated thrombus formation. The diameter of the excluded aneurysm was decreased in 54 patients (91.5%) during the follow-up period. There were no type I endoleaks, but there were 3 type II endoleaks; 2 of the 3 type II endoleaks disappeared during the follow-up period. Additional endovascular operations were performed in 3 patients. There were 10 in-hospital deaths (14.5%), and the incidences of stroke, spinal cord injury and distal embolism were 11.6%, 5.8% and 2.9%, respectively. The 1- and 3-year survival rates were 84.8% and 79.4%, respectively, and the 1- and 3-year freedom from reintervention rates were 97.2% and 81.3%, respectively.

CONCLUSIONS

The J-graft open stent graft was easy to deploy, and it could shift the distal anastomosis to a more proximal side. The mid-term performance of this device was good. It has the potential to provide one-stage repair.

Acute Kidney Injury Affects Mid-Term Outcomes of Thoracoabdominal Aortic Aneurysms Repair

The effect of acute kidney injury (AKI) on mid-term outcomes following thoracoabdominal aortic aneurysm (TAAA) repair is not well known. We hypothesized that postoperative AKI would reduce mid-term survival and aimed to analyze the effect of AKI on mid-term outcomes after TAAA repair. This retrospective study identified 294 consecutive TAAA repairs at Kobe University Hospital from October 1999 to March 2019. Patients with preexisting end-stage renal disease that required hemodialysis (n = 11) and patients who died intraoperatively (n = 2) were excluded. Finally, 281 patients were analyzed. AKI was defined according to Kidney Disease: Improving Global Outcomes guidelines (KDIGO) classification. Of the 281 patients, 178 (63.3%) developed AKI, of which 98 (34.9%) had mild, 34 (12.1%) had moderate, and 46 (16.4%) had severe AKI. Twenty-six patients (12.8%) required renal replacement therapy after surgery. Twenty-three in-hospital deaths (8.2%) were recorded, including 2 (0.7%) without AKI, 0 (0%) with mild AKI, 1 (0.4%) with moderate AKI, and 20 (7.1%) with severe AKI (p < .001). The 4-year survival was 91.9 ± 3.0% for no AKI, 91.3 ± 3.2% for mild AKI, 72.4 ± 8.5% for moderate AKI and 32.6 ± 7.4% for severe AKI (p < .001). Multivariable Cox-hazard regression analysis demonstrated that moderate and severe AKI, older age and emergency surgery were significant risk factors for mid-term survival. In patients undergoing TAAA repair, severe AKI was associated with an increase in in-hospital mortality and both moderate and severe AKI were negatively associated with mid-term survival. Preventing moderate/severe AKI may improve mid-term survival after TAAA repair.

Severe intraluminal atheroma and iliac artery access affect spinal cord ischemia after thoracic endovascular aortic repair for degenerative descending aortic aneurysm

OBJECTIVES

This study aimed to reveal additional factors potentially contributing to the multifactorial ethiopathogenesis of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (TAA).

METHODS

The medical records of 293 patients who underwent TEVAR without debranching procedures for descending TAA between 2011 and 2018 were retrospectively reviewed. We excluded the following cases from the study: 72 patients with aortic dissection; 15 with rupture; 14 with anastomotic pseudoaneurysm; 22 with re-TEVAR; 34 without evaluation of the artery of Adamkiewicz (AKA). Sufficient data were available for 136 patients (79% men; mean age of 76 ± 7.4 years). We conducted univariable and multivariable analyzes using the logistic regression analysis to assess the relationship between pre-/intraoperative factors and postoperative SCI.

RESULTS

SCI was observed in nine patients (6.8%). Severe intraluminal atheroma [odds ratio (OR), 6.23; p = 0.014] and iliac artery access (OR 4.65; p = 0.043) were identified as the positive predictors of SCI by univariable analysis. Risk factors of SCI were determined additionally as follows: coverage of the intercostal artery branching AKA (ICA-AKA) (OR 4.89; p = 0.054); coverage of the ICA-AKA combined with iliac access (OR 10.1; p = 0.002); that combined with severe intraluminal atheroma (OR 13.7; p = 0.001).

CONCLUSION

Severe intraluminal atheroma and iliac artery access were the independent predicting factors of SCI after TEVAR for degenerative descending TAA. In patients with complicated aortoiliofemoral access route, coverage of the ICA-AKA is associated with the risk of SCI.

Early Gastrointestinal Complications After Open Thoracoabdominal Aortic Aneurysm Repair

BACKGROUND

The present study was done to examine the incidence, predictors, and impact of early gastrointestinal (GI) complications after open thoracoabdominal aortic aneurysm repair.

METHODS

We retrospectively analyzed data from 3587 open thoracoabdominal aortic aneurysm repairs performed at our center from 1986 to 2019. We used univariate analyses and multivariable logistic regression to identify risk factors associated with GI complications, including bleeding, ischemia, obstruction, and acute pancreatitis. Adverse event was defined as operative death or persistent stroke, paraplegia, paraparesis, or renal failure necessitating dialysis.

RESULTS

Gastrointestinal complications developed after 213 repairs (5.9%). Gastrointestinal complications less often developed after extent I repair than after repairs that involved infrarenal abdominal aortic segments (ie, extent II to IV repairs; P = .003). Patients who had GI complications more often underwent endarterectomy, stenting, or bypass of visceral arteries (51.2% vs 42.2%; P = .01). Use of selective visceral perfusion did not differ between groups. Patients who had GI complications had higher rates of operative mortality (34.3% vs 6.6%) and adverse events (44.1% vs 13.2%) and had longer hospitalization (29 vs 11 days; P < .001 for all). Independent predictors of GI complications included incidental splenectomy, rupture, non-extent I repair, older age, and longer aortic cross-clamp time. Short-term, midterm, and long-term survival were poorer for patients who had GI complications (P < .001).

CONCLUSIONS

Although uncommon, early GI complications after open thoracoabdominal aortic aneurysm repair are associated with significant early and late morbidity and mortality. Development of perioperative strategies to mitigate these complications is warranted.