Type IV thoracoabdominal aneurysm repair: predictors of postoperative mortality, spinal cord injury, and acute intestinal ischemia.

Our purpose was to identify preoperative and intraoperative predictors of early mortality, spinal cord injury, or acute intestinal ischemia after repair of type IV thoracoabdominal aneurysm (TAA IV) as a basis for optimizing surgical indications and techniques. From January 1991 to June 2006 we operated on 171 patients for TAA IV. There were 149 men (87.1%) and 22 women (12.9%), with a mean age of 65.0 +/- 10.9 years (range 23-82). The underlying etiology was degenerative aneurysmal disease in 143 patients (83.6%). Twenty-two patients (12.8%) underwent emergent operation. Comorbidity included coronary disease in 72 patients (45.6%) including 39 who had undergone a revascularization procedure, arterial hypertension in 121 (70.1%), chronic obstructive pulmonary disease in 81 (47.4%), and chronic kidney insufficiency in 58 (33.9%). Seventy-six patients (44.4%) presented concurrent lesions involving at least one visceral artery. Spinal cord arteriography was performed in 91 patients (53.2%). In 25 cases (27.5%) arteriographic findings demonstrated the need for revascularization of the Adamkiewicz artery due to location of the ostium at or below the T12 level. Repair was carried out with cross-clamping only in 160 cases (93.6%). Partial cardiopulmonary bypass was used in 11 patients (6.4%). A total of 23 patients (13.4%) died postoperatively. The cause of death was acute intestinal ischemia in nine cases, multiple organ failure in seven, coagulation disorder in three, cardiac complications in two, and stroke in two. Spinal cord injury occurred in eight patients (4.7%) including two who died. According to univariate analysis, the significant predictors of early death were age over 70 years, degenerative aneurysmal disease, coronary artery disease, chronic renal insufficiency or visceral artery lesions, operator, duration of intestinal ischemia and use of a "complex" surgical technique. Although the only significant predictor of spinal cord injury was duration of digestive ischemia, an almost significant trend (p < 0.1) was observed for coronary artery disease, coronary bypass, and renal insufficiency. The significant predictors of acute intestinal ischemia were kidney insufficiency and visceral artery lesions, but coronary artery disease and previous coronary bypass were almost significant (p = 0.06). Frequent association of TAA IV with arteriosclerotic disease in elderly patients presenting coronary artery disease and chronic kidney insufficiency partly explains why early postoperative mortality remains high. The incidence of spinal cord injury suggests that preoperative spinal cord arteriography is mandatory for prevention. The frequency of intestinal ischemia is more problematic, but a better understanding of the underlying mechanism should enable development of preventive strategies.

Combined infrarenal aorta and carotid artery reconstruction: early and late outcome in 152 patients.

Between January 1, 1985 and December 31, 1998, we performed combined infrarenal aorta and carotid artery reconstruction in 152 consecutive patients. The mean age of these patients was 65.4 +/- 8.6 years (range, 43-88 years). Infrarenal aortic disease involved abdominal aortic aneurysm in 78 patients (44.7%) and occlusive aortoiliac lesions in 84 (55.3%). Carotid artery disease was detected by performing routine Doppler ultrasonography prior to aortic reconstruction. A total of 121 carotid lesions were asymptomatic (79.6%). A total of 32 patients (21%) had a history of contralateral carotid repair. Eighty-one patients (53.2%) presented with coronary artery disease diagnosed on the basis of clinical and/or laboratory testing. Concurrent lesions were diagnosed in the renal arteries of 43 patients (28.3%) and in the visceral arteries of 16 (10.5%). Based on the results of cardiac evaluation, eight patients underwent coronary revascularization before combined reconstruction. Renal or visceral artery reconstruction was carried out during the same procedure in 30 (19.7%) and 10 (6.6%) patients, respectively. Univariate analysis demonstrated six factors that were significantly associated with perioperative mortality and morbidity: age, coronary artery disease, chronic obstructive pulmonary disease, procedure time, intraoperative blood loss, and creatinemia over 140 micromol/L. Multivariate analysis showed that only the first four of these factors were independent. Actuarial survival in the overall population, including the patients who died during the perioperative period, was 73.9 +/- 7.1% at 5 years and 50.9 +/- 10% at 10 years. From our experience, we conclude that combined infrarenal aorta and carotid artery reconstruction can be performed with no additional operative risks and consequently is the strategy of choice. In our series neither procedure had any effect on the early or late outcome of the other. Our experience suggests that combined surgery is a safe alternative to staged surgery in patients with concurrent lesions involving the infrarenal aorta and carotid artery bifurcation.