RESUMO
OBJECTIVE: To review short-term outcomes and long-term survival and durability after open surgical repairs for chronic distal aortic dissections in patients whose anatomy was amenable to thoracic endovascular aortic repair (TEVAR). METHODS: Between February 1991 and August 2017, we repaired chronic distal dissections in 697 patients. Of those patients, we enrolled 427 with anatomy amenable to TEVAR, which included 314 descending thoracic aortic aneurysms (DTAAs) and 105 extent I thoracoabdominal aortic aneurysms (TAAAs). One hundred eighty-five patients (44%) had a history of type A dissection, and 33 (7.9%) had a previous DTAA/TAAA repair. Variables were assessed with logistic regression for 30-day mortality and Cox regression for long-term mortality. Time-to-event analysis was performed using Kaplan-Meier methods. RESULTS: Thirty-day mortality was 8.4% (n = 36). In all, 22 patients (5.2%) developed motor deficit (paraplegia/paraparesis), and 17 (4.0%) experienced stroke. Multivariable analysis identified low estimated glomerular filtration rate (eGFR; <60 mL/min/1.73 m2), previous DTAA/TAAA repair, and chronic obstructive pulmonary disease (COPD) as associated with 30-day mortality. Patients without all 3 risk factors had a 30-day mortality rate of 2.6%. During a median follow-up of 6.5 years, 160 patients died. The survival rate was 81% at 1 year and 61% at 10 years. Cox regression analysis identified preoperative aortic rupture, eGFR <60 mL/min/1.73 m2, previous DTAA/TAAA repair, COPD, and age >60 years as predictive of long-term mortality. Forty-five patients required subsequent aortic procedures, including 8 reinterventions to the treated segment. Freedom from any aortic procedures was 85% at 10 years, and aortic procedure-free survival was 45% at 10 years. Hereditary aortic disease was the sole predictor for any aortic interventions (hazard ratio, 3.2; P = .004). CONCLUSIONS: Open surgical repair provided satisfactory low neurologic complication rates and durable repairs in chronic distal aortic dissection. Patients without low eGFR, redo, and COPD are the low-risk surgical candidates and may benefit from open surgical repair at centers with similar experience to ours. Patients with hereditary aortic disease warrant close surveillance.
RESUMO
BACKGROUND: The purpose of this study was to redefine indications of open descending and thoracoabdominal aortic aneurysm repair in the younger population. METHODS: Between 1991 and 2017, 2012 patients undergoing descending and thoracoabdominal aortic aneurysm repair at our institution were divided into 2 groups for comparison: younger (<50 years; 276 [14%]) and older (≥50 years; 1736 [86%]). Patient demographics and perioperative outcomes were retrospectively reviewed. RESULTS: Younger patients had significantly more heritable thoracic aortic disease (HTAD; 53% vs 9%, P < .001) and chronic dissections (64% vs 26%, P < .001) and fewer comorbidities. The younger cohort underwent more extent II repairs (28% vs 15%, P < .001). Operative mortality was significantly lower in younger patients (6% vs 17%, P < .001). Significant disabling complications (composite of operative mortality, paraplegia/paraparesis, stroke, and dialysis) were seen in 17% of the younger patients and in 40% of older patients 40% (P < .001). In multivariate analysis, extent of repair and chronic obstructive pulmonary disease were independent predictors for significant disabling complications in the younger cohort. Additional aortic interventions were required in 12% in the younger group and in 4% in the older group (P < .001), and nearly one-third were in the treated segment (ie, treatment failure) in both groups. Younger patients requiring additional reintervention had significantly higher incidence of HTAD (66% vs 9%, P < .001). Survival rate was significantly higher in the younger patient group, with a 10-year survival rate of 74.6% ± 2.9% vs 40.7% ± 1.3% (log-rank P < .001). CONCLUSIONS: Patients younger than 50 years with descending and thoracoabdominal aortic aneurysm have low surgical risks, and open repairs can be performed with excellent short-term and durable long-term results. Open surgical repairs should be considered initially in younger patients requiring descending and thoracoabdominal aortic aneurysm repairs. HTAD warrants closer postoperative surveillance.
