Operative Mortality and Morbidity in Ruptured Abdominal Aortic Aneurysms in the Endovascular Age.

BACKGROUND: Controversy exists about technique of repair for ruptured abdominal aortic aneurysms (rAAA). We studied rAAA treated at a single tertiary center from 2005 to 2015 to determine operative morbidity and mortality in open and endovascular aortic aneurysm repair (EVAR) of rAAA. METHODS: All rAAA (n = 144) treated from 2005 to 2015 were reviewed using an IRB-approved database. "EVAR first" strategy was used after 2010. rAAA treatment was open (rAAA began with open surgery); EVAR (rAAA began with EVAR and included EVARs converted to open); and EVAR only (successful EVAR). Preoperative, intraoperative and outcome variables were analyzed with t-test, chi-square and logistic and multivariate regression using SAS. RESULTS: One hundred forty-four rAAAs were treated from 2005 to 2015. Seventy-five percent (108/144) began with open surgery. Twenty-five percent (36/144) began with EVAR. After 2010, 54.5% began with EVAR. Eleven percent of EVARs (4/36) converted to open and 89% (32/36) had EVAR only. Fifty-nine percent (83/144) had preoperative systolic blood pressure (SBP) <90 mm Hg. Eighty-four percent of these (70/83) had open surgery and 16% (13/83) had EVAR. Hospital mortality for all rAAAs was 23.6% (34/144). Operative mortality was 25% (27/108) in open and 19.4% (7/36) in EVAR (P = 0.486). Mortality was 75% (3/4) in EVARs that converted to open and 12.5% (4/32) in EVAR only patients. In univariate analysis age, ASA 5, preoperative SBP <90 mm Hg, intraoperative complications, dialysis, MI/CHF, respiratory failure, stroke and reintervention were significant for mortality. In multivariate modeling preoperative SBP <90 mm Hg (P = 0.0018), ASA 5 (P = 0.0175), intraoperative complications (P = 0.0017), MI/CHF (P = 0.0045), respiratory failure (P = 0.0159) and new renal failure (P = 0.0073) were significant for mortality. There was no difference in mortality between open and EVAR (P = 0.9554) and no difference in cardiac or respiratory failure. Open had more renal failure and EVAR more endoleaks. Fifty-eight percent (21/36) of EVARs started with local anesthesia (LA) and 52.8% (19/36) finished with LA. Nineteen percent (4/21) of EVARs with LA versus 60% (9/15) with general anesthesia (GA) had preoperative SBP <90 mm Hg. In EVAR only there was no difference in mortality between LA (4/18, 22.2%) and GA (3/14, 21.4%) (P = 0.94). CONCLUSIONS: Operative mortality in ruptured AAA was associated with hypotension, ASA status 5, uncontrolled hemorrhage, cardiac events, and respiratory failure but not with type of repair. EVAR and open surgery also had comparable cardiac and respiratory morbidity. Selection was critical in EVAR for rAAA because mortality of unsuccessful EVAR was very high. There was no difference in mortality between LA and GA for EVAR.

Advances in Treatment and Long-term Survival in Patients with Descending Thoracic Aortic Aneurysms Treated at a Single Tertiary Center from 1984 to 2014.

BACKGROUND: We report long-term survival in open surgical and endovascular patients treated for descending thoracic aortic aneurysms (TAAs) at a single tertiary center from 1984 to 2014 to study the impact of transition to thoracic endovascular aortic repair (TEVAR) for TAA repair. METHODS: Using a prospectively maintained registry, all patients (n = 202) having open or endovascular repair (TEVAR) of descending TAAs were studied. Date of last contact or death was obtained on all patients from hospital records, Social Security Death Database, and verified online records. Survival curves were computed and compared by age, preoperative variables, surgical approach, and hospital complications. Proportional hazards models were used for multivariate analysis of survival. RESULTS: In total, 28% had dissection, 41.6% presented acutely, 68.8% had TEVAR, and 31.1% had open surgery. Spinal cord injury (SCI) occurred in 0.5% and stroke in 1%. Operative mortality (5.9%) was associated with acuity, respiratory failure, open approach, and age. One-year survival in all patients was 83.7%. One-year mortality was associated with acuity, open surgery, respiratory failure, hospital complications, and coronary artery bypass surgery (CABG). Five-year survival was 60.4% and not associated with other variables. One-year survival was 76% in open patients and 87% in TEVAR patients. When operative mortality was excluded, 1-year survival was 89% and 5-year survival was 64.2% and there was no difference in long-term survival between TEVAR and open surgery. One-year mortality was associated with CABG and hospital complications. No variables were associated with 5-year survival. Ten-year survival was 35% and predicted only by age at operation. CONCLUSIONS: Operative mortality was higher in open surgery than TEVAR, but after 30 days, long-term survival was the same. Eighty-nine percent of patients were alive 1 year after surgery and 64% were alive 5 years after surgery. Low SCI contributed to longer survival.

Intraoperative neuroprotective interventions prevent spinal cord ischemia and injury in thoracic endovascular aortic repair.

OBJECTIVE: Transient and permanent paraparesis and paraplegia (spinal cord injury [SCI]) are reported in up to 13% of patients undergoing thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm, thoracoabdominal aortic aneurysm, and thoracic aortic dissection. We hypothesize that aggressive intraoperative and postoperative neuroprotective interventions prevent or significantly reduce all SCI in TEVAR. METHODS: Using a prospectively maintained, Institutional Review Board-approved database, we retrospectively reviewed all TEVARs performed in a university tertiary referral center from 2005 to 2014 to study the incidence of all transient and permanent lower extremity SCI. Only TEVARs for traumatic aortic tear were excluded. Arch debranching and carotid subclavian bypass were performed before TEVAR in patients with arch involvement. All patients had moderate systemic hypothermia (34°C), mean arterial pressure ≥90 mm Hg, and hemoglobin ≥10 g/dL. Patients received mannitol (12.5 g), methylprednisolone (30 mg/kg), and naloxone (1 µg/kg/h). Patients in whom >12 cm of aortic coverage was planned had spinal fluid drained to a pressure of <8 mm Hg intraoperatively and postoperatively until normal leg strength was confirmed. The main outcome measure was transient or permanent SCI. RESULTS: One hundred fifty-five patients had TEVAR between 2005 and 2014. Mean age was 74 years, and 56.1% were male. Descending thoracic aortic aneurysm was present in 91.6%, thoracoabdominal aortic aneurysm in 8.4%, and dissection in 28.8%. Presentation was acute in 42.5%. The procedure included carotid-subclavian bypass in 18.7% of patients. Seventy-two percent of patients had spinal fluid drainage. Mean aortic coverage was 25 cm. Eighty-one percent of patients had >12 cm aortic coverage, and 49% had complete coverage of the thoracic aorta (coverage from subclavian to celiac artery). In-hospital mortality was 1.94%. Stroke occurred in 1.32% of patients. No patient had renal failure. SCI occurred in 0.65% (1 of 154) of patients. CONCLUSIONS: SCI in TEVAR can be significantly reduced by using proactive intraoperative and postoperative neuroprotective interventions that prolong spinal cord ischemic tolerance and increase spinal cord perfusion and oxygen delivery.

The effect of intercostal artery reimplantation on spinal cord injury in thoracoabdominal aortic aneurysm surgery.

OBJECTIVE: Intercostal artery (ICA) reimplantation (ICAR) is thought to decrease spinal cord injury (SCI) in thoracic aortic aneurysm and thoracoabdominal aortic aneurysm (TAAA) surgery. Patients treated from 1989 to 2005 without ICAR were compared with those treated from 2005 to 2013 with ICAR to determine whether ICAR reduced SCI. We hypothesized that ICAR would reduce SCI, especially in the highest-risk patients. METHODS: This was a retrospective analysis using a prospectively maintained Investigational Review Board-approved database from a university tertiary referral center. The analysis included all patients (n = 805) undergoing thoracic aortic aneurysm and TAAA surgery from 1989 to 2013. The main outcome measure was any transient or permanent paraplegia or paraparesis (SCI). From 1989 to 2004, ICAR was not performed in patients, and open ICAs were ligated; from 2005 to 2013, open ICAs at T7 to L2 were reimplanted in patients with Crawford type I, II, and III TAAAs. Surgical technique was cross clamp without assisted circulation. Anesthetic management was the same from 1989 to 2013. Demographic, intraoperative, and outcome variables were assessed by univariate and multivariate analysis. Observed/expected ratios for paralysis were calculated. RESULTS: A total of 540 patients had surgery before 2005, and 265 had surgery after 2005, when ICAR was begun. There were 275 type I, II, and III TAAAs before 2005 and 164 after 2005. Aneurysm extent, acuity, SCI, mortality, renal failure, and pulmonary failure were the same in patients treated before and after 2005. Multivariate modeling of all patients showed type II TAAA (P = .0001), dissection (P = .00015), and age as a continuous variable (P = .0085) were significant for SCI. Comparing only type I, II, and III TAAAs, there was no difference in SCI between those with ICAR after 2005 and those without ICAR before 2005 (5.1% vs 8.8%; P = .152). In a subanalysis of the highest-risk patients (type II, dissection, acute), ICAR was not significant (P = .27). Observed/expected ratios ratios were 0.23 before 2005 and 0.16 after 2005 (χ2 = .796; P = .37). CONCLUSIONS: Although there was a small decrease in SCI with ICAR, reattaching ICAs did not produce a statistically significant reduction in SCI, even in the highest-risk patients.

Postoperative renal failure in thoracoabdominal aortic aneurysm repair with simple cross-clamp technique and 4°C renal perfusion.

OBJECTIVE: Acute renal failure (ARF) is reported in up to 12% of patients after thoracoabdominal aortic aneurysm (TAAA) repair with assisted circulation. ARF increases mortality, reduces quality of life, and increases length of hospital stay. This study analyzes ARF after TAAA repair done without assisted circulation. METHODS: A retrospective analysis of all patients treated for TAAA from 2000 to 2013 was performed using a concurrently maintained, institutionally approved database. All surgeries used simple cross-clamp technique, with moderate systemic hypothermia (32°-33°C) and renal artery perfusion with 4°C solution. Serum creatinine concentration was measured preoperatively and 1 day, 3 days, 7 days, and 30 days after surgery, and Cockcroft-Gault estimated glomerular filtration rate (eGFR) was calculated. Kidney injury was classified by RIFLE (Risk, Injury, Failure, Loss of kidney function, End-stage renal disease) eGFR criteria. Changes in eGFR, kidney injury, ARF, dialysis, length of stay, mortality, and risk factors for ARF were analyzed with SAS-JMP software (SAS Institute, Cary, NC) for univariate analysis and multivariate modeling. RESULTS: From 2000 to 2013, 455 patients had TAAA surgery; 116 (25.5%) were acute. Mean preoperative eGFR was 62.3 mL/min. Mean renal ischemia time was 58.9 minutes. Eighteen patients (4%) had ARF; nine (2%) required temporary dialysis, and three (0.66%) required permanent dialysis. In univariate analysis, age, renal ischemia time, acuity, baseline eGFR, previous aortic surgery, surgical blood loss, and return to operating room for bleeding complications were significant for ARF (P < .05). Sex, aneurysm extent by Crawford type, cardiac index and mean arterial pressure after reperfusion, and use of loop diuretics were not significant for ARF. In a stepwise deletion model, acute (P = .0377), previous aortic surgery (P = .0167), return to operating room (P = .0213), and age (P = .0478) were significant for ARF. Surgical blood loss (P = .0056) and return to operating room (P = .0024) were significant for postoperative dialysis in multivariate analysis. Only surgical blood loss was significant for permanent dialysis in a multivariate model (P = .0331). CONCLUSIONS: Very low ARF after TAAA repair can be achieved by simple cross-clamp technique with moderate systemic hypothermia and profound renal cooling. Age, preoperative eGFR, previous aortic surgery, return to operating room, and surgical blood loss were significant for ARF. Return to operating room for bleeding and surgical blood loss were significant for dialysis. Baseline eGFR <30 mL/min and postoperative dialysis were significant for mortality. Most patients with ARF, even those with temporary dialysis after TAAA repair, recover renal function to near preoperative levels.

Low incidence of paraplegia after thoracic endovascular aneurysm repair with proactive spinal cord protective protocols.

OBJECTIVE: Paraparesis and paraplegia after thoracic endovascular aneurysm repair (TEVAR) is a greatly feared complication. Multiple case series report this risk up to 13% with no, or inconsistent, application of interventions to enhance and protect spinal cord perfusion. In this study, we report our single-institution experience of TEVAR, using the same proactive spinal cord ischemia protection protocol we use for open repair. METHODS: Endovascular thoracic aortic interventions were performed for both on-label (aneurysm) and off-label (trauma, other) indications. Aortic area covered was recorded as a fraction from the subclavian to celiac origins and reported as a percentage. If debranching was required, measurements were taken from the most distal arch vessel left intact. Intraoperative imaging and postoperative computed tomographic angiogram were used in calculating aortic percent coverage. Outcomes were recorded in a clinical database and analyzed retrospectively. The spinal cord ischemia protection included routine spinal drainage (spinal fluid pressure <10 mm Hg), endorphin receptor blockade (naloxone infusion), moderate intraoperative hypothermia (<35°C), hypotension avoidance (mean arterial pressure >90 mm Hg), and optimizing cardiac function. RESULTS: From 2005 to 2012, 94 consecutive TEVARs were studied. Indications were thoracic aneurysm (n = 48), plaque rupture with or without dissection (n = 23), trauma (n = 15), and other (n = 8). Forty-nine percent were acute, average age was 68.5 years, 60% (n = 56) were male, and the mean follow-up was 12 months. Mean length of aortic coverage was 161 mm, correlating to 59.4% aortic coverage. One patient had delayed paralysis (1.1%; observed/expected ratio, 0.12) and recovered enough to ambulate easily without assistance. Other complications included wound (7.5%), stroke (4.3%), myocardial infarct (4.3%), and renal failure (1.1%). CONCLUSIONS: Proactive spinal cord protective protocols appear to reduce the incidence of spinal ischemia after TEVAR compared with historical series. This study would suggest that active, as opposed to reactive, approaches to spinal ischemia portend a better long-term outcome. Multimodal protection is essential, especially if long segment coverage is planned.

Blunt thoracic aortic injury: open or stent graft repair?

BACKGROUND: Despite a lack of level I evidence, endovascular stent grafting is frequently used for the treatment of blunt thoracic aortic injury. The purpose of this study is to compare the outcomes between open and endovascular repair of traumatic rupture of the thoracic aorta. METHODS: This article is based on a single-institution review of all consecutive patients treated for blunt aortic injury at the University of Wisconsin Hospital and Clinics between October 1999 and May 2007. This study was reviewed and approved by the institutional review board. Patients were identified from our Level 1 trauma registry. Inclusion criteria for this study was based on computed tomographic or angiographic evidence of thoracic aortic injury distal to the left subclavian artery. Two groups were identified: patients who underwent open repair (OR) and, patients who underwent endovascular repair (ER). Patient demographics, mechanism of injury, Injury Severity Score, associated injuries, comorbid conditions, intraoperative findings, postoperative complications, and duration of hospital stay were analyzed. Data regarding these patients and their injuries were retrieved from our trauma registry as well as chart review and outpatient records. The outcomes from OR and ER were compared using the Fisher exact test. P values less than 0.05 were considered statistically significant. RESULTS: During the 8-year period, 26 consecutive patients were treated for blunt aortic injury (OR = 12 and ER = 14). There were 20 men, and the mean age was 36 years. There were no differences between the groups in the mechanism of injury, Injury Severity Score, or number of associated injuries on initial presentation. On an intent-to-treat basis, the endovascular therapy was technically successful 100% of the time. There was no procedure-related mortality. There was 1 patient, however, in the OR group with presumed recurrent laryngeal nerve palsy. There was no incident of treatment-related paraplegia in either group. The 1-year survival for OR and ER patients was 93% and 92%, respectively. At 1 year, 25% of patients in the OR group and 18% of patients in the ER group required reinterventions. Mean operating room time was 309 minutes for the ERs and 383 minutes for the patients who underwent OR. Intraoperative blood product administration was greater in the OR group (P = .055); there was no difference between the groups, however, in the total blood products administered for a given hospital stay. The mean duration of hospital stay was 13 days for the OR group and 13.9 days for the ER group. CONCLUSION: There were no significant differences with respect to morbidity or mortality between these 2 groups. These data suggest that ER is at least as safe as OR for blunt aortic injury.

Effect of MR angiography on the diagnosis and treatment of patients with suspected renovascular disease.

PURPOSE: Although the diagnostic accuracy of renal magnetic resonance (MR) angiography is established, its effect on referring physicians is unknown. The authors prospectively measured the effect of MR angiography results on referring physicians' diagnosis and treatment (plans) of patients with suspected renovascular disease. MATERIALS AND METHODS: Referring physicians prospectively completed questionnaires before and after MR angiography was performed during evaluation of their patients with suspected renovascular disease. The questionnaires asked them to estimate the probability (0%-100%) of their most likely diagnosis before and after receiving the imaging information. They were also asked for their anticipated and final treatment plans. The authors calculated the mean gain in diagnostic percentage confidence and the proportion of patients with changed initial diagnoses or anticipated management. A paired t-test was used to assess significance of the gains in diagnostic percentage confidence. RESULTS: Physicians prospectively completed pre- and post-MR-angiography questionnaires for 30 patients. MR angiography improved mean diagnostic certainty by 35% (P < .0001). MR angiography changed physicians' initial diagnoses in 12 patients (40%). Anticipated treatment plans were changed in 20 patients (67%). Invasive procedures were avoided in eight patients (27%). CONCLUSION: MR angiography has a substantial effect on the diagnostic and therapeutic decision-making of physicians managing patients with suspected renovascular disease.

Minimal incision aortic surgery.

PURPOSE: In this study we evaluated the clinical and economic impact of minimal incision aortic surgery (MIAS) for treatment of patients with abdominal aortic aneurysms (AAAs) and aortoiliac occlusive disease (AIOD). METHOD: Fifty patients with either AAA (34) or AIOD (16), prospectively treated with the MIAS technique, were compared with 50 patients (40 AAA and 10 AIOD) treated in the same time period with long midline incision and extracavitary small bowel retraction. MIAS was also compared with a cohort of 32 patients with AAA treated by means of endoaortic stent-grafts. Outcomes and cost (based on metric mean length of stay) were compared for the open and endoaortic techniques. RESULTS: Patients who experienced no perioperative complications after the MIAS or endovascular repair technique had shorter hospital stays than patients with uncomplicated aortic repairs performed with a traditional long midline abdominal incision (3 days vs 3 days vs. 7.2 days). Hospital stay was also significantly shorter for the less invasive procedures when perioperative complications were included (4.8 days vs. 4.3 days vs 9.3 days). The MIAS and endovascular aortic repair groups had a shorter intensive care unit stay (< or = 1.0 day) and a quicker return to general dietary feeding (2.5 days) than patients treated with standard open repair (1.8 days, 4.7 days). The overall morbidity for the MIAS technique (14%) and endovascular technique (21%) was not significantly different from standard open repair (24%). The mortality rate for the different treatment groups was equivalent (MIAS, 2%; endovascular repair, 3%; standard repair, 2%). The MIAS was more cost-efficient than standard open repair ($12,585 vs $18,445) because of shorter intensive care unit and hospital stay and was more cost-efficient than endoaortic repair ($12,585 vs $32,040) because of reduced, direct intraoperative costs. CONCLUSIONS: MIAS is as safe as standard open or endovascular repair in the treatment of AAA and AIOD. MIAS is more cost-efficient than standard open or endoaortic repair.

Magnetic resonance angiography of aorto-iliac disease.

BACKGROUND: Four different techniques for aorto-iliac magnetic resonance angiography (MRA) were assessed for accuracy using a digital subtraction angiography (DSA) gold standard. Surgeons' confidence in their ability to generate treatment plans with MRA and DSA was assessed, in consultation with a radiologist. METHODS: Two different two-dimensional (2D) time-of-flight (TOF) sequences, a phase-contrast sequence, and a contrast-enhanced (CE) MRA sequence were used. Receiver operating characteristic (ROC) curves were plotted and areas (A(z)) calculated from radiologists' readings. Surgeons' confidence in their ability to utilize the images for treatment planning was assessed with a 5-point Likert scale. Thirty-six patients were evaluated. RESULTS: CE MRA had a sensitivity, specificity, and A(z) of.92,.93, and.96, respectively, for stenoses 50% or greater. CE MRA performed better than other sequences, but the improvement compared with gated 2D TOF was not statistically significant. Interobserver agreement for CE MRA and DSA yielded identical Kappa values. Surgeons were most confident in DSA, followed by CE MRA, which was significantly preferred to other techniques. CONCLUSIONS: CE MRA closely approximates DSA in terms of diagnostic accuracy. Surgeons considering treatment plans are confident in the CE MRA technique, relative to other MRA methods.

Less invasive aortic surgery: the minilaparotomy technique.

BACKGROUND: This study evaluated a less invasive technique for exposure of the infrarenal aorta and its impact on the treatment of patients with abdominal aortic aneurysms (AAA) or aortoiliac occlusive disease (AIOD), or both. METHODS: Forty patients with AAA (26), aneurysmal extension into the iliac arteries (6), or AIOD (8) were prospectively selected for minilaparotomy aortic exposure and repair using a small periumbilical midline incision (< or =10 cm); intra-abdominal, nondisplaced retraction of the small bowel; and conventional hand-sewn vascular anastomoses. Perioperative comparisons with a contemporary group of AAA patients treated with long, open midline incision and extracavitary small bowel retraction were made. RESULTS: There was no significant difference between the minilaparotomy and open surgical control groups for operating room time; intraoperative, perioperative morbidity; or mortality. Significant differences were documented between the minilaparotomy and the control group with regard to stay in the intensive care unit (days; 1.0+/-1.2 versus 1.8+/-1.5); return to general diet (days; 3+/-1.3 versus 4.7+/-2.8); and length of stay (days; 4.9+/-1.8 versus 7.3+/- 3.4). CONCLUSIONS: Minilaparotomy exposure is safe and effective for treatment of infrarenal AAA and AIOD. This technique maintains quality outcome while reducing postoperative ileus, hospital stay, and resource utilization.

Yield of repeated screening for abdominal aortic aneurysm after a 4-year interval. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators.

BACKGROUND: Little is known about the rate at which new abdominal aortic aneurysms (AAAs) develop or whether screening older men for AAA, if undertaken, should be limited to once in a lifetime or repeated at intervals. METHODS: A large population of veterans, aged 50 through 79 years, completed a questionnaire and underwent ultrasound screening for AAA. Of these, 5151 without AAA on the initial ultrasound (defined as infrarenal aortic diameter of 3.0 cm or larger) were selected randomly to be invited for a second ultrasound screening after an interval of 4 years. Local records and national databases were searched to identify deaths and AAA diagnoses made during the study interval in subjects who did not attend the rescreening. RESULTS: Of the 5151 subjects selected for a second screening, 598 (11.6%) had died (none due to AAA), and 20 (0.4%) had an interim diagnosis of AAA. A second screening was performed on 2622 (50.9%), of whom 58 (2.2%; 95% confidence interval, 1.6%-2.8%) had new AAA. Three new AAAs were 4.0 to 4.9 cm, 10 were 3.5 to 3.9 cm, and 45 were 3.0 to 3.4 cm. Independent predictors of new AAA at the second screening included current smoker (odds ratio, 3.09; 95% confidence, 1.74-5.50), coronary artery disease (odds ratio, 1.81; 95% confidence interval, 1.07-3.07), and, in a separate model using a composite variable, any atherosclerosis (odds ratio, 1.97; 95% confidence interval, 1.16-3.35). Adding the interim and rescreening diagnosis rates suggests a 4-year incidence rate of 2.6%. Rescreening only in subjects with infrarenal aortic diameter of 2.5 cm or greater on the initial ultrasound would have missed more than two thirds of the new AAAs. CONCLUSIONS: A second screening is of little practical value after 4 years, mainly because the AAAs detected are small. However, the incidence that we observed suggests that a second screening after longer intervals (ie, more than 8 years) may provide yields similar to those seen in initial screening and therefore warrants further study.

Preliminary experience with minilaparotomy aortic surgery.

This prospective nonrandomized study assessed clinical outcomes of a minilaparotomy technique (MLT) used for elective graft repair of infrarenal aortic aneurysm (AAA) and/or aortoiliac occlusive disease (AIOD). Twenty-three patients requiring infrarenal AAA or aortofemoral bypass underwent a small periumbilical midline incision, nondisplacement of the small bowel, and a traditional vascular anastomosis. Results from these procedures were compared with those from contemporaneous procedures performed in the standard transabdominal (STA) fashion (n = 21). Age, weight, and comorbid conditions were comparable between groups. Patients requiring concomitant renal, mesenteric, or infrainguinal revascularization were excluded. Operating time, length of stay in the intensive care unit (ICU), number of oral feeding times, and length of hospital stay were recorded. There were no significant differences in age, operative time, or aneurysm size between the MLT and STA groups. With the MLT then were significant decreases in ICU stay (1 vs. 1.8 days), length of time to return to a general diet (3 vs. 4.7 days), and length of stay (4.9 vs. 7.3 days.) Morbidity and mortality were not statistically different between groups. Patients undergoing the MLT have reduced ICU and hospital stay, and decreased post operative ileus. The MLT does not increase operating room costs or require expensive laparoscopic equipment or the extended postoperative radiographic surveillance needed after endovascular repair.

Clamp and sew techniques in thoracoabdominal aortic surgery using naloxone and CSF drainage.

Surgical repair of thoracoabdominal (TAA) and thoracic aneurysm is challenging, with the potentials for high morbidity and mortality. There is no standardized operative approach. Operative management of TAA consists of simple clamp-and-sew techniques with adjuncts, cerebrospinal fluid (CSF) drainage, naloxone administration, and intraoperative hypothermia, to protect the spinal cord. The use of CSF drainage and naloxone administration has reduced paraplegia to 3.4%, compared with 21% when none of these adjunctive spinal cord measures were used. The authors discuss their operative strategy, surgical technique, and results at the University of Wisconsin Hospital and Clinics.

Thoracoabdominal aortic aneurysm. How we do it.

A systematic approach to paraplegia risk in the surgical treatment of thoracoabdominal aortic aneurysms based on effective strategies identified from the experimental literature is discussed. With this approach, collateral blood flow, rather than direct intercostal reimplantation, moderate hypothermia and endorphin receptor, is emphasized blockade. The result has been a 10-fold reduction in paraplegia risk in elective patients and a 5-fold reduction in acute patients. This reduction in paralysis risk has resulted in improved short- and long-term survival.

Comparison of treatment plans for lower extremity arterial occlusive disease made with electrocardiography-triggered two-dimensional time-of-flight magnetic resonance angiography and digital subtraction angiography.

BACKGROUND: The purpose of the study was to determine whether preoperative treatment plans for patients with lower extremity ischemia can be made with electrocardiography (EKG)-triggered two-dimensional (2D) time-of-flight (TOF) magnetic resonance angiography (MRA) as accurately as digital subtraction angiography (DSA). METHODS: Forty patients were prospectively evaluated with the combination of EKG-triggered 2D TOF MRA, DSA, and pulse volume recordings. Blinded reviewers graded arterial segments for disease severity. Accuracy of separate MRA- and DSA-based treatment plans was compared with the procedures performed based on all available information. RESULTS: There was an 86% exact match between MRA- and DSA-based plans (92% MRA and 94% DSA accuracy). The MRA-based plan accurately predicted 90% of suprainguinal and 95% of infrainguinal procedures, whereas the DSA-based plan accurately predicted 100% of suprainguinal and 85% of infrainguinal procedures. Two-year primary patency was 83% for all procedures. Radiologists' review of disease severity resulted in a mean exact correlation between studies of 81% (kappa = 0.64). The agreement between radiologists interpreting the MRA was 84% (kappa = 0.7) compared with 82% (kappa = 0.66) for the DSA. CONCLUSIONS: MRA- and DSA-based preoperative management plans were of comparable efficacy. Significant interobserver variability was seen with the interpretations of both preoperative studies. EKG-triggered 2D TOF MRA can be used to plan arterial reconstructions; however, all patients require arterial pressure measurements prior to suprainguinal repair and confirmatory intraoperative angiography during infrainguinal revascularization.