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edo Lateral Thoracotomy for Reoperativeescending and Thoracoabdominal Aortic Repair:Consecutive Series of 60 Patients
hristian D. Etz, MD, PhD, Stefano Zoli, MD, Fabian A. Kari, MS,hristoph S. Mueller, MS, Carol A. Bodian, DrPH, Gabriele Di Luozzo, MD,onstadinos A. Plestis, MD, and Randall B. Griepp, MD
epartments of Cardiothoracic Surgery and Anesthesiology, Mount Sinai School of Medicine, New York, New York
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Background. Reoperative descending thoracic aortaDTA) or thoracoabdominal aortic aneurysm (TAAA)urgery is a challenge because of increased risk of lungnjury and diffuse bleeding.
Methods. Sixty patients (34 male, mean age 54.4 years)nderwent redo thoracotomy for DTA (22 patients) orxtended thoracoabdominal incision for reoperativeAAA (38 patients) from March 1988 to June 2007, after.7 � 0.9 previous cardioaortic procedures. Forty-oneatients were hypertensive (68%), 18 were smokers
30%), 9 had Marfan syndrome (15%), 9 had coronaryrtery disease (15%), 5 had chronic obstructive pulmo-ary disease (8%), and 3 had diabetes mellitus (5%). Inll, 45% (27 patients) had previous dissection, 30% (18)ad atherosclerotic aneurysms, 15% had coarctation sur-ery (9), and 6 patients had other etiologies. Mean fol-ow-up, 100% complete, was 6.5 years.
Results. Hospital mortality for reoperative DTA/TAAAas 13.3% (8 patients). Although 6.3 � 2.9 (0 to 14)
egmental artery pairs were sacrificed at reoperation—nd 6.2 � 2.3 (1 to 12) initially—for a total of 10.6 � 3.9 (2o 15) segmental artery pairs sacrificed, only 1 patient had
araplegia (1.6%). Four patients had a 2-day procedure,IlpcWli
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ery, Mount Sinai School of Medicine, One Gustave L. Levy Pl, New York,Y 10029; e-mail: [email protected].
2009 by The Society of Thoracic Surgeonsublished by Elsevier Inc
ith 12 to 24 hours of intensive care unit recovery afterysis of extensive adhesions: all survived. Respiratoryomplications occurred in 13 patients (21.6%), and per-anent dialysis was required in 2 (3.3%), but there were
o strokes. Adverse outcome—1-year mortality, stroke,ermanent dialysis, or paraplegia—occurred in 13 pa-
ients (21.6%). Adverse outcome was marginally associ-ted (p < 0.2) with increased age, atherosclerotic aneu-ysms (33% versus 17% other), TAA incision (30% versus%), and greater aneurysm extent, and was significantlyssociated with perfusion technique (p � 0.02). Adverseutcome occurred in 3 of 4 patients who had clamp-and-ew technique, 6 of 21 using partial cardiopulmonaryypass (28.6%), and 3 of 17 with partial left heart bypass
17.7%), but only 1 of 18 with hypothermic circulatoryrrest (5.6%).Conclusions. Reoperative DTA/TAAA repair was sig-
ificantly safer with hypothermic circulatory arrest ratherhan partial cardiopulmonary bypass, partial left heartypass, or clamp-and-sew strategy. A 2-day procedureay be advisable for patients with extensive adhesions.
(Ann Thorac Surg 2009;88:758–67)
© 2009 by The Society of Thoracic Surgeonseoperative descending thoracic aorta (DTA) or tho-racoabdominal aortic aneurysm (TAAA) surgery is a
hallenge because of increased risk of lung injury andiffuse bleeding. The incidence of respiratory complica-
ions has been reported to be as high as 30%; diffuseleeding requiring surgical revision occurs in as many as3% [1, 2].Reoperative patients have been reported to be an
verage of 7 years older than patients presenting forrimary procedures, and appear to present more oftenith renal failure, cerebrovascular disease, atheroscle-
otic heart disease, more extensive aneurysms (Crawford
ccepted for publication April 28, 2009.
resented at the Forty-fifth Annual Meeting of The Society of Thoracicurgeons, San Francisco, CA, Jan 26–28, 2009.
ddress correspondence to Dr Etz, Department of Cardiothoracic Sur-
I/III), and rupture, and are more often symptomatic andikely to have preexisting spinal cord injury [3]. Theirreoperative risk profile predicts a likelihood of signifi-ant operative mortality and postoperative morbidity.
e suspect that the fear of an adverse outcome has oftened to the reluctance of surgeons to undertake evenndicated reoperations in some patients.
Increasing life expectancy and initial surgical treat-ent of aortic disease at an advanced age are likely
urther to increase the mean age of patients in need ofeoperation, since patients with thoracic aortic aneu-ysms are at a substantial risk of having subsequentneurysms in previously unoperated segments of theorta [4]. Natural history studies have demonstrated thatseparate aneurysm involving the abdominal aorta de-
elops in at least 25% of patients initially presenting withthoracic aortic aneurysm. Pressler and McNamara [5]
ound separate abdominal aortic aneurysms in 26 of 90
atients (28.9%) with nondissecting thoracic aortic aneu-0003-4975/09/$36.00doi:10.1016/j.athoracsur.2009.04.140
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ysms: 4 of these 26 patients (15.4%) died of a rupturedbdominal aortic aneurysms.Patients with multilevel or recurrent aortic aneurysmal
isease thus represent a complex cardiovascular thera-eutic challenge as rupture of a second aneurysm is a
requent cause of death after successful aortic aneurysmepair [6, 7]. In patients who originally presented withortic aneurysms involving the ascending, transverserch, or descending segments, Crawford and coworkers7] reported that multiple aneurysms developed in nearly0%; in contrast, multiple aneurysms developed in only2% of patients who initially had abdominal aortic aneu-ysms. New or recurrent aortic aneurysms accounted forbout 30% (36 of 130) of thoracic aortic reoperationseported by Carrel and colleagues [8].
Because alternatives to surgery are often not availableor complex aortic disease, innovative strategies to man-ge the technical challenges are mandatory to alloweoperative procedures to be successful. At present, al-hough surgical treatment is usually necessary to preventupture and improve survival in patients with multipleneurysms, data regarding the risks associated withultiple aortic operations have been conflicting. Most
resent the results of more proximal aortic operationsfter infrarenal abdominal aortic aneurysm repair [9].revious reports of small series have described earlyortality rates ranging from 25% to 28.6% [10-12]. A
ontemporary series describes a 30-day mortality of1.4% [4].
The reported outcomes after surgical repair of multi-evel and recurrent aortic aneurysms vary widely. Spe-ific information regarding the results of TAAA repairfter previous thoracic aneurysm repair through a lefthoracotomy are limited, and thus the safety of TAAAepair in patients with previous thoracic aneurysm repairhrough left thoracotomy remains somewhat uncertain.o clarify these issues—and to establish a standardgainst which future endovascular and hybrid ap-roaches can be compared—we retrospectively evalu-ted our 20-year experience with TAAA repair in patientsith previous thoracic aneurysm repair through a left
horacotomy.
aterial and Methods
review of our institutional database disclosed 60 pa-
Abbreviations and Acronyms
CSF � cerebrospinal fluidDTA � descending thoracic aortaTAAA � thoracoabdominal aortic aneurysmHCA � hypothermic circulatory arrestLHB � left heart bypassMEP � motor evoked potentialsSA � segmental arterySSEP � somatosensory evoked potentials
ients who underwent redo thoracotomy for DTA (22 r
atients; 36.7%) or extended thoracoabdominal incisionor reoperative TAAA (38 patients; 63.3%) from March988 to June 2007. The Institutional Review Board ap-roved this research; additional patient consent was notequired.
atient Demographicshirty-four were male (56.7%); mean age was 54.4 � 16.7ears (median 55; range, 13 to 80). Forty-one patients68%) were hypertensive, 18 (30%) were smokers, 9 (15%)ad Marfan syndrome, 9 (15%) had coronary arteryisease, 5 (8%) had chronic obstructive pulmonary dis-ase, and 3 (5%) were diabetic. Table 1 summarizes thelinical characteristics of all patients who underwentedo lateral thoracotomy. The average number of previ-us cardioaortic procedures was 1.7 � 0.9. Most of theeoperated patients had undergone one previous opera-ion, but 18 had had two previous procedures, 9 had hadhree, and 2 had undergone four previous aortic proce-ures, of which at least one was carried out through a left
ateral thoracotomy.Patients with multiple previous operations often had
ongenital aortic defects that involved coarctation (9atients; 15%) or Marfan syndrome (9 patients,; 15%).he principal indications for reoperative surgery werehronic dissection in 27 patients (45%), and atheroscle-
able 1. Patient Demographics and Clinical Risk Profile
emographic Number
exMale 34 (56.7%)Female 26 (43.3%)ge, yearsMean � SD 54.4 � 16.7Range 13–80
tiologyDissection 27 (45%)Atherosclerotic 18 (30%)Coarctation 9 (15%)Pseudoaneurysm 2 (3.3%)Mycotic 2 (3.3%)Other 2 (3.3%)arfan’s syndrome 9 (15%)hronic obstructive pulmonary disease 5 (8.3%)moker 18 (30%)oronary artery disease 9 (15%)Requiring previous
Coronary artery bypass graft surgery 4Stent 1
ypertension 41 (68.3%)nsulin-dependent diabetes mellitus 3 (5%)hronic hemodialysis 4 (6.6%)revious neurological dysfunctionTransient ischemic attack 1 (1.6%)Stroke 2 (3.3%)Preoperative paraplegia 1 (1.6%)
otic aneurysms in 18 patients (30%).
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760 ETZ ET AL Ann Thorac SurgREDO LATERAL THORACOTOMY FOR AORTIC REPAIR 2009;88:758–67A
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revious Procedures in Reoperated Patientsixty consecutive patients underwent redo lateral thora-otomy after a total of 102 previous cardioaortic proce-ures, of which more than 90% involved the thoracic orbdominal aorta. Eighty-six were previous thoracic aorticneurysm repairs: 3 ascending aortic aneurysm repairs, 8entall procedures, 11 coarctation repairs, 12 completerch repairs (7 as the first stage of an elephant trunkrocedure), 39 descending thoracic aortic operations, 13
horacoabdominal operations, and 6 abdominal aorticneurysm repairs. The remaining patients had, in addi-ion, aortic valve replacements (2), coronary artery by-ass graft surgery (4), and various other procedures (4).he interval between the first and the last thoracotomyas 7.6 years on average (median interval 5.2; interquar-
ile range, 0 to 32).
able 2. Intraoperative Details
etail Number
rgent/emergent operation 13 (21.6%)umber of previous operationsMean � SD 1.7 � 0.85Range 1–4ortic sizeMean � SD 67.5 � 12.2 mmRange 52–117 mmortic graftSize 23 mmRange 10–34 mm
erfusion strategyNone 4 (7%)PCPB 21 (35%)PLHB 17 (28%)HCA 18 (30%)CA time 37 � 9 minelective cerebral perfusion timea 31 � 12 minean esophageal temperature with
HCA13.4 � 1.9°C
eimplanted visceral arteries, numberof patients
Celiac 27 (45%)Superior mesenteric 27 (45%)Renal 28 (47%)Intercostal/lumbar 5 (7%)
SEP monitoring 46 (77%)EP monitoring 20 (33%)erebrospinal fluid drainage 32 (53%)umber of segmental arteries
sacrificedMean � SD 6.3 � 2.9Range 0–14
Utilized in 12 patients.
CA � hypothermic circulatory arrest; PCPB � partial cardiopulmo-
eary bypass; PLHB � partial distal aortic perfusion with left heartypass.
urgical ManagementRTERIAL CANNULATION. Arterial cannulation was carriedut either through the femoral artery (n � 50; 89%), theistal transverse arch/previously placed aortic graft
n � 5; 9%), or (in 1 patient; 2%) through the right axillaryrtery. Venous cannulation was established with a wire-irected catheter placed in the right atrium through the
emoral vein.YPOTHERMIC CIRCULATORY ARREST. Hypothermic circulatoryrrest (HCA) was used in 18 patients (30%) and wasffected by surface (cooling blanket) and perfusion cool-ng. The decision to utilize HCA was prompted byechnical considerations, often involving the feasibilitynd safety of clamping the aorta proximal to the repair. IfCA was anticipated early in the procedure, the patientas cooled during the initial period of cardiopulmonaryypass. A minimum of 30 minutes of cooling was utilized.n some patients in whom HCA was instituted later in theperative procedure, the patient was maintained at aerfusion temperature of 20°C until about 15 minutesefore HCA, after which the blood temperature was
owered to 10°C. Adequate cerebral cooling was assuredn all cases by a jugular venous saturation greater than5% and an esophageal temperature of 12° to 15°C. In allatients for whom more than 20 minutes of HCA wasnticipated, the head was packed circumferentially in ice.he average cerebral ischemia time during HCA was7 � 9 minutes (median 36; range, 22 to 57) at a meansophageal temperature of 13.4 � 1.9°C. Perfusion warm-ng was carried out at the end of the procedure, with theradient between the esophageal and blood temperatureaintained at less than 10°C. Warming was maintained
ntil esophageal temperature reached 35°C, and bladderemperature was greater than 32°C. Downward drift,owever, resulted in most patients leaving the operatingoom at esophageal and bladder temperatures of 32°C.
arming was usually accomplished in 1 hour of perfu-ion; during the last 15 or 20 minutes, partial bypass wasrequently utilized to take advantage of improved warm-ng with pulsatile perfusion. Intraoperative details for thentire series are summarized in Table 2.ELECTIVE CEREBRAL PERFUSION. Perfusion of the arch vesselsnd coronary arteries was achieved during upper bodyerfusion utilizing an arm graft in 11 patients and
hrough the right axillary artery in 1 patient. Perfusionas at a blood temperature of 15° to 20°C, with flow
ufficient to maintain a radial artery pressure of 50 to 60m Hg. This usually required a flow of 1,000 to 1,500
c/min. The average duration of upper body perfusionas 31 � 12 minutes (median 31; range, 11 to 55) at aean esophageal temperature of 13 � 2°C.
ARTIAL CARDIOPULMONARY BYPASS. Partial cardiopulmonaryypass was used in 21 patients (35%). In all cases, righttrial drainage was established through the commonemoral vein and the catheter position monitored byransesophageal echocardiography. A centrifugal pumpnd cardiopulmonary bypass circuit without a reservoiras utilized at flows of 2,000 to 4,000 cc/min. The mean
sophageal temperature during partial cardiopulmonary
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ypass was 30.9 � 1.9°C, with an average duration oferfusion of 122 � 64 minutes. For visceral perfusion,dditional catheters were used in 13 patients for theidneys, for the superior mesenteric artery, and for theeliac trunk.ARTIAL LEFT HEART BYPASS. Left heart bypass (LHB) wassed in 17 patients (28%). Left atrial to femoral arteryypass was adjusted to maintain equal pressures abovend below. Arterial cannulation was through a commonemoral artery in 15 patients (88%), and through a centralannula (namely, in the proximal descending aorta or theistal arch) in 2 patients (12%). The left atrium wasrained directly in 5 patients (29%) and through the left
nferior pulmonary vein in 12 patients (71%) using aioMedicus circuit (Medtronic Biomedicus Inc, Edenrairie, MN) without a reservoir. Flows varied from 1,500
o 4,000 cc/min, and the average duration of LHB was 6036 minutes at a mean esophageal temperature of 32 �
.4°C.
TA/TAAA Repair Techniquehe aneurysm was dissected free from mediastinal tis-ue. The intercostal and lumbar arteries remaining afterhe previous aortic repair were dissected and temporaryccluded. If MEP and SSEP remained unchanged, theegmental vessels were sacrificed before opening theneurysm to avoid backbleeding and possible steal fromhe spinal cord circulation. In general—in view of theirmportance in supporting spinal cord perfusion—lamping of the subclavian artery was avoided, and thenternal mammary artery and the superior epigastric axisere preserved. If clamping of the distal aorta was not
easible or unsafe, the distal anastomosis was performedrst, and distal perfusion restored after cross clamping of
he graft. Vascular Dacron grafts (Hemashield; Bostoncientific, Natick, MA), 18 to 34 mm, with as many as
hree additional side arms, were implanted in an end-to-nd fashion. For the visceral segment, a beveled anasto-osis was frequently utilized. If the visceral segment
equired circumferential replacement, the visceral ves-els were occluded with a balloon catheter and intermit-ently perfused with cold blood before being directlynastomosed to the graft or connected utilizing interven-ng graft segments (8 to 12 mm Dacron).
evascularization of the Visceral Segmenttotal of 30 patients (50%) underwent reimplantation of
t least one visceral vessel: in these cases, partial cardio-ulmonary bypass was used in 17 patients (57%); LHBas performed in 7 patients (23%); a clamp-and-sew
epair was performed in 4 patients (13%); and 2 patients7%) underwent deep HCA. The superior mesentericrtery and the celiac trunk were reimplanted in 27atients: the preferred technique for reimplantation was
hrough an additional side arm in the main graft (n � 18;7%) followed by a Carrel patch (n � 9; 30%). The renalrteries were reimplanted in 28 patients: in 20 cases71%), an additional graft was utilized; in 8 cases (22%), a
utton technique was preferred. iotor Evoked Potential Monitoringfter induction, volatile anesthetics were discontinued,s were muscle relaxants, and narcotic anesthesia wasubstituted. Motor evoked potentials (MEPs) were elic-ted by a train of nine transcranial electrical pulseselivered from a Digitimer D185 cortical stimulator (Wel-yn, Garden City, UK). The stimuli were applied
hrough two disposable corkscrew electrodes (Nicoletiomedical, Madison, WI) anchored in the scalp overly-
ng the left and right motor cortices, respectively, approx-mately 6 to 8 cm lateral from vertex. In response totimulation, MEPs (composed of compound muscle ac-ion potentials) were recorded from the skin over theibialis anterior (leg) and abductor pollicis (hand) mus-les through subdermal needle electrodes. The record-ngs from the hands permit evaluation of the effects ofnesthesia and temperature on the amplitudes of theEPs. The signals were amplified, filtered, digitized, and
aved to hard drive. The stimulation intensity was set to0% above the level that elicited the maximal MEPmplitude for each patient. A decrease of 50% in ampli-ude of the leg MEPs in the presence of stable hand MEPsas considered to reflect a lower body ischemic event.he MEP monitoring has been performed in 20 patientsince 2002.
omatosensory Evoked Potential Monitoringomatosensory evoked potentials (SSEPs) were elicitedy stimulation of the left and right posterior tibial nerves
hrough two surface disk electrodes placed approxi-ately 2.0 cm apart below the medial malleolus at the
nkle. Recordings were made from the scalp overlyinghe somatosensory cortex using subdermal needle elec-rodes placed approximately 3 to 4 cm behind vertex andeferenced to an electrode at FPz on the forehead. Around electrode was placed on the shoulder. The re-orded signals were amplified, filtered, and saved to hardrive. The responses to 200 to 300 stimuli were averaged.
schemic spinal cord dysfunction was defined as a decreasen SSEP amplitude of more than 50%. The SSEP monitoringas been performed in 46 patients since 1993. In 45 of 46ases, MEP and SSEP remained unchanged during theourse of serial segmental artery sacrifice, or could beeturned to baseline levels by anesthetic and blood pres-ure manipulation. One patient had loss of SSEPs and
EPs late intraoperatively, and is discussed below.
egmental Artery Sacrifice and MEP/SSEPn average of 10.6 � 3.9 segmental artery (SA) pairs
median 12; range, 2 to 15) were sacrificed overall—6.2 �.3 during previous aortic procedures (median 6; range, 1o 12) and 6.3 � 2.9 during the redo lateral thoracotomymedian 6; range, 0 to 14). In 83% of patients, almost 90%f all SAs (in average 6.1 � 1.7 SA pairs) were sacrificedetween T7 and L1, where the artery of Adamkiewicz isresumed to arise. In 80% of patients (47 of 60), an averagef 5.9 �1.8 SAs were sacrificed between T9 and L3—an areaf the spinal cord that has been suggested to be particularly
mportant by Biglioli and coworkers—without MEP/SSEP
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oss [13]. During the early period of this study, 5 patientsad SA reimplantation, 1 after SSEP loss. The extent ofegmental artery sacrifice in each patient, and the level ofntersegmental artery resection, are shown in Figure 1, withhe patients in chronological order.
erebrospinal Fluid Drainagecatheter for drainage of cerebrospinal fluid (CSF) has
een placed routinely in 32 patients since 1995. Cerebro-pinal fluid pressure was monitored during the operationnd for the subsequent 48 to 72 hours: CSF was drainedt a maximum rate of 15 cc/hour as long as CSF pressureemained above 10 mm Hg.
ostoperative Managementhe SSEPs were monitored until the patient awakened.hereafter, hourly brief neurological examinations wereerformed for 72 hours. High normal blood pressuresere maintained, aiming for a mean aortic pressure of 90m Hg. The CSF drainage was continued for 48 to 72
ig 1. Extent of segmental artery sacrifice inach of the 60 patients. The white part of thear represents the level of sacrifice during previ-us procedures, and the black part represents thextent of the resection during redo lateral thora-otomy for descending thoracic aorta/thoracoab-ominal aortic aneurysm repair. Some patientsid not have segmental artery sacrifice at theime of original operation, as with coarctationepair.
ig 2. Kaplan-Meier survival curve for all patients (n � 60) afteredo lateral thoracotomy for descending thoracic aorta/thoracoab-
mominal aortic aneurysm repair.
ours, and methylprednisolone was used for 72 hours1,000 mg, day 0; 375 mg, day 1; 250 mg, day 2).
ollow-Upatients were followed by their referring cardiologist andontacted periodically by our research personnel. Annualomputed tomography scans were scheduled for all pa-ients. Postoperative events were compiled and analyzedccording to the Guidelines for Reporting Morbidity andortality after Cardiac Valvular Operations and our
nstitutional check list. For this study, the follow-up waslosed on December 13, 2007, and was 100% complete.ollow-up time for the entire cohort (n � 60) ranged fromto 19 years (median 4), with an average of 4.8 � 4.3
ears. Long-term survival was evaluated for the 48 pa-ients still alive 1 year postoperatively (median follow-up.7 years; range, 0.1 to 18).
tatistical Methodsata were entered in Excel spreadsheets and transferred
o a SAS file (SAS Institute, Cary, NC) for data descrip-ion and analysis. Patient and disease characteristics areescribed as percents, median (range) or means (stan-ard deviation). The two major outcomes considered aredverse outcome among all patients in the sample, andong-term survival among patients who were alive 1 yearfter their surgery. For the latter, follow-up time started 1ear after the procedure date and terminated at thearliest of death or last contact alive.Factors were tested for association with adverse outcome
y �2 tests or logistic regression, as appropriate. Long-termurvival probabilities were estimated from a Kaplan-Meierife table. We also estimated the annual death rate for thisroup per person-year of follow-up, as well as the standard-
zed mortality ratio. This gives the observed numbers ofeaths relative to the number that would be expected basedn New York State population death rates for comparablege, sex, and follow-up times. Statistical significance of thetandardized mortality ratio was tested under a Poisson
odel, implemented with SAS Proc Genmod.
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763Ann Thorac Surg ETZ ET AL2009;88:758–67 REDO LATERAL THORACOTOMY FOR AORTIC REPAIR
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esults
ospital mortality for reoperative DTA/TAAA was 13.3%8 patients). Adverse outcome—1-year mortality, stroke,ermanent dialysis, or paraplegia—occurred in 13 pa-
ients (21.6%). The overall survival was 80% at 1 year, 62%t 5 years, and 56% at 10 years after surgery (Fig 2).
wo-Day Proceduresour patients (7%) had a 2-day procedure. They wereermitted 12 to 24 hours of intensive care unit recovery timefter lysis of extensive adhesions during dissection andobilization of the aorta during the first operative day to
llow bleeding to subside and for clearance of pulmonaryecretions before institution of cardiopulmonary bypass.one of the patients undergoing 2-day procedures re-uired subsequent reexploration for bleeding (Table 4). Allpatients survived, but 1 experienced spinal cord injury.
anagement of SAslthough 6.3 � 2.9 (median 6; range, 0 to 14) SA pairsere sacrificed at reoperation and 6.2 � 2.3 (median 6;
ange, 1 to 12) initially—for a total of 10.6 � 3.9 (median2; range, 2 to 15) SA pairs sacrificed—only 1 patient1.6%) had spinal cord injury.
ostoperative Courseospital mortality—defined as death in the hospital orithin 30 days postoperatively— for reoperative DTA/AAA was 13.3% (8 patients; Table 3). The mean age of
he patients who died was 61 � 13.2 years. Three patients
able 3. Postoperative Course and Complications of thentire Cohort (n � 60)
Number
ospital mortality 8 (13.3%)araplegia 1 (1.7%)leeding requiring reoperation 3 (5%)enal insufficiency 7 (11.6%)Creatinine � 1.6 mg/dL 3 (5%)Temporary dialysisa 2 (3.3%)Permanent dialysis 2 (3.3%)
espiratory complications 13 (21.6%)Tracheotomy 5 (8.3%)ECMO 1 (1.7%)
ardiac complications 2 (3.3%)Cardiac arrest 1 (1.7%)Ventricular fibrillation 1 (1.7%)
ntensive care unit stay, daysMean � SD 3.5 � 2.9Range 0–12ospital stay, daysMean � SD 15.1 � 14.4Range 0–68
Patients did not require further dialysis after discharge.
CMO � extracorporeal membrane oxygenation.
ied intraoperatively: 2 had cardiac failure, and 1 patient
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ad uncontrollable bleeding from the pulmonary arterynd was found only at autopsy to have had an extensiveistiosarcoma mimicking a pseudoaneurysm.Five patients died postoperatively while in the hospi-
al. One patient had a ruptured mycotic aneurysm, ar-ived at our institution in septic shock, and died within 8ours after the procedure of the consequences of preop-rative exsanguination. Two patients suffered postoper-tive adult respiratory distress syndrome, 1 after extra-orporeal membrane oxygenation. Two patients died ineptic shock, 1 after graft infection and 1 after ischemicolitis. Among all patients who died in the hospital, 3atients (38%) had an urgent/emergent operation, and 7
88%) had undergone reimplantation of at least oneisceral vessel.
ostoperative Complicationserious bleeding requiring reoperation occurred in 3atients (5%). Severe respiratory complications required
racheotomy in 5 patients. Extracorporeal membranexygenation support was necessary in 1 patient; 7 pa-ients (11.6%) had prolonged initial intubation or re-uired reintubation.Only 1 patient (1.6%) had spinal cord injury. This
ypertensive patient had been operated on with LHB,nd delayed onset paraparesis was detected on theecond postoperative day. All aortic segmental arteriesad been sacrificed: T9 to L4 during reoperation, and T3
o T8 during the first procedure, 4 years earlier. Cerebro-pinal fluid drainage could not be established during the
able 5. Univariate Analysis on 60 Patients After Redo Later
No. of Patients
therosclerosisYes 18No 42gea
erfusion techniqueNone 4PCPB 21PLHB 17HCA 18verall segmental arteries sacrificed2–3 74–5 166–7 158–9 8� 9 13
horacoabdominal incisionYes 37No 23
ariables associated (p � 0.2) with adverse outcome. Factors were testeppropriate. a Analyzed as continuous variable.
CA � hypothermic circulatory arrest; PCPB � partial cardiopulmon
econd operation, and equivocal intraoperative SSEP a
ecordings with a poor signal were attributed to technicalroblems. A magnetic resonance imaging scan per-
ormed 2 days after the procedure showed spinal cordnjury at the level of T8. After a short period of rehabil-tation, the patient recovered some motor function, ande was able to ambulate with assistance at the time ofischarge, but currently is wheelchair bound.
dverse Outcomedverse outcome was defined as paraplegia, permanentemodialysis, or stroke within 30 days after operation, oreath within 1 year after operation. An adverse outcomeccurred in 13 patients (21.6%). Adverse outcome wasarginally associated—but without reaching statistical
ignificance (0.05 � p � 0.2)—with increased age, athero-clerotic aneurysms, thoracoabdominal incision, andreater aneurysm extent. Perfusion technique was thenly variable with a significant (p � 0.02) impact upondverse outcome (Table 5). Adverse outcome occurred inof 4 patients (75%) who had clamp-and-sew technique,
n 6 patients (28.6%) using partial cardiopulmonary by-ass, and in 3 patients (17.7%) with partial LHB. Only 1atient of the 18 with HCA (5.6%), however, experiencedn adverse outcome.
ong-Term Survivalong-term survival was evaluated for the 48 patients still
oracotomy
Adverse Outcome
o. of Events Percent Odds Ratio p Value
6 33.3 2.5 0.187 16.7 1.0
0.03/year 0.15
3 75 51 0.026 28.6 4.93 17.7 3.61 5.6 1.0
0 0.0 (2–5) 1.0 0.155 31.32 13.3 (6–7) 1.80 0.06 46.2 (� 8) 1.4
11 29.7 4.4 0.112 8.7 1.0
association with adverse outcome by �2tests or logistic regression, as
ypass; PLHB � partial left heart bypass.
al Th
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live 1 year after surgery. Ten of them died during this
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eriod, giving a linearized death rate of 4.17% per pa-ient-year. The 10 observed deaths can be compared with.0 expected deaths based on New York State rates foromparable ages, sex, and follow-up times, giving atandardized mortality ratio of 2.5 (95% confidence inter-al: 1.3 to 4.6, p � 0.004).The higher annual death rates of 1-year survivors
esulted in estimated long-term survival probabilities of8% 1 year later, 93% 2 years later, and 69% 5 years later.orresponding survival rates for the age- and sex-atched New York State population are 99%, 99%, and
6%, respectively (Fig 3).
omment
revious reports have painted a confusing picture of theisks involved in reoperation for a thoracic or thoracoab-ominal aortic aneurysm in patients who have had pre-ious cardiac or aortic surgery. We suspect that fear of andverse outcome may deter many surgeons from at-empting reoperation in patients with otherwise un-quivocal indications for aneurysm repair, leaving theatients at significant risk of death from rupture.Gloviczki and colleagues [14] reviewed the Mayo Clinic
xperience of 102 consecutive patients with multiple aorticneurysms who underwent 201 aortic reconstructions. Thenitial operations involved the thoracic aorta in 65 patients63.7%), and were limited to the lower abdominal aorta in 3736.3%); TAAA repair was performed as a subsequentrocedure in 37 patients (36.3%). Overall operative mortal-
ty increased with the number of procedures: 4.4% for therst operation, 10.4% for the second, and 33.3% for the
hird. In contrast, of the 1,509 patients in Crawford’s com-lete TAAA experience, reported by Svensson and col-
eagues [15], 181 (12%) had a previous proximal aorticperation: compared with the patients without previous
ig 3. Kaplan-Meier survival curve (dots) for the 48 patients stilllive 1 year after redo lateral thoracotomy for descending thoracicorta/thoracoabdominal aortic aneurysm repair compared with ange- and sex-matched New York State population (solid line).
horacic aortic repair, this group was characterized by a e
ower 30-day mortality rate (4% with previous thoracicortic repair versus 9% without previous thoracic aorticepair; p � 0.025) and a lower incidence of postoperativeenal failure (8% versus 19%; p � 0.0004), although thereas an increased incidence of paraplegia (20% versus
5%; p � 0.05). The Crawford series statistics suggesthe possibility that some patients with high risk factorsere denied operation for fear of a high operativeortality, and raise the specter of a higher risk of
araplegia in these patients.Our experience suggests that the overall mortality andorbidity are within acceptable ranges, especially given
hat there is at present no real alternative to surgery inerms of preventing rupture, which is a potent threat.ndovascular approaches in this situation hold out someromise, but are likely to be complicated endeavors,iven the need in 50% of the current cohort for vascular-
zation of visceral vessels, and the risks associated withn additional debranching procedure. Furthermore, suit-ble landing zones to permit stent placement are notikely to be present in all patients. Stent placement mayot be appropriate in patients with connective tissueisorders. The long-term results with stent placement aren especial concern in this cohort, which included aelatively high proportion of younger patients.
With regard to spinal cord injury, we did not find whatppears to be a significantly enhanced risk: only 1 patientxperienced parapaplegia. In this patient, a magneticesonance imaging study showed localized spinal cordnjury at the level of T8, one segmental level away fromhe center of all the segmental arteries sacrificed. Thisupports our theory, derived from experimental studies,uggesting that the collateral network’s flow reserveeclines progressively toward the middle of the longitu-inal center of SAs sacrificed, while it supplies sufficientlood flow at the cranial and caudal margins of theesected aneurysm [16, 17]. The occurrence of spinal cordnjury in this case also supports the concept of direct
easurement of spinal cord perfusion pressure: lowevels of spinal cord perfusion pressure might havelerted the surgical team to take more seriously thequivocal SSEP readings that had been observed intra-peratively [18]. The occurrence of spinal cord injury inhis patient also underscores the importance of meticu-ous postoperative as well as intraoperative neuromoni-oring, and the value of CSF drainage.
From this retrospective review, we have made therguably surprising observation that reoperative DTA/AAA repair seems to be significantly safer with HCAather than partial cardiopulmonary bypass, partial LHB,r a clamp-and-sew strategy. Recent experience withirect spinal cord perfusion pressure monitoring hasuggested that spinal cord perfusion pressures are not asigh with either of these nonpulsatile distal perfusion
echniques as with cardiopulmonary bypass. It is possi-le that deep HCA may provide better protection foroth the viscera and the spinal cord during prolongedrocedures than any form of partial bypass under mod-
rate hypothermia. Many surgeons avoid use of deep
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766 ETZ ET AL Ann Thorac SurgREDO LATERAL THORACOTOMY FOR AORTIC REPAIR 2009;88:758–67A
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CA for fear of excessive bleeding, but this has not beenproblem in our experience or in other large series
tilizing HCA for DTA/TAAA repair [19–21].The success of the 2-day approach to patients with
xtensive adhesions is very encouraging. In addition tollowing bleeding to subside after lysis of extensivedhesions, this technique also allows the surgical teamo approach the critical portions of the reconstructive op-ration with fresh energy and attention, rather than afterany hours of frustrating but necessary preliminary
issection. The 2-day strategy may have contributed tohe successful use of deep HCA in conjunction withxtensive thoracoabdominal aneurysm repair, as neitherf the 2 patients in whom both techniques were used haderious bleeding complications.
Although an overall mortality of 13% and an adverseutcome of 22% are still far from ideal, these results muste viewed in relation to the substantial risk of notperating: the 60 patients in this patient cohort had anverall average aneurysm diameter of 6.8 � 1.2 cm (6.6 �.4 cm among those with dissection, and 6.9 cm in thoseith nondissecting aneurysms). We think that these op-
rative results will prove useful for evaluating studies ofutcomes using endovascular or hybrid approaches, whichay become more appealing alternatives in the future. An
wareness of the natural history of these lesions—thatubsequent operation or endovascular intervention may beeeded—should prompt greater use of creative strategies,uch as placement of antegrade and reverse elephantrunks, as well as transposition of visceral vessel attach-
ents, during initial operations for thoracic aortic aneu-ysms, specifically to facilitate later interventions.
But even those patients in this series who underwentuccessful operation and survived the first postoperativeear still suffered an accelerated death rate thereafter,ompared with an age- and sex-matched control popula-ion. The finding that the observed mortality for this redoateral thoracotomy cohort was relatively high (4.2% peratient/year), exceeding the expected death rate of an age-nd sex-matched control population almost 2.5-fold, sug-ests that careful assessment of a patient’s long-term ben-fits is needed before opting for elective surgery, especiallyor patients who have several preoperative risk factors.ong-range planning at the time of initial surgery, further
echnical innovations, and use of endovascular techniquesill undoubtedly improve the immediate risk of reopera-
ion, but may have limited impact on the long-term outlook.
eferences
1. Svensson LG, Hess KR, Coselli JS, Safi HJ, Crawford ES. Aprospective study of respiratory failure after high-risk sur-gery on the thoracoabdominal aorta. J Vasc Surg 1991;14:271–82.
2. Kawaharada N, Morishita K, Fukada J, Hachiro Y, TakahashiK, Abe T. Thoracoabdominal aortic aneurysm repair throughredo left-sided thoracotomy. Ann Thorac Surg 2004;77:
1304–8.3. Coselli JS, Poli de Figueiredo LF, LeMaire SA. Impact ofprevious thoracic aneurysm repair on thoracoabdominalaortic aneurysm management. Ann Thorac Surg 1997;64:639–50.
4. Lombardi JV, Carpenter JP, Pochettino A, Sonnad SS, Ba-varia JE. Thoracoabdominal aortic aneurysm repair afterprior aortic surgery. J Vasc Surg 2003;38:1185–90.
5. Pressler V, McNamara JJ. Thoracic aortic aneurysm: naturalhistory and treatment. J Thorac Cardiovasc Surg 1980;79:489–98.
6. Plate G, Hollier LA, O’Brien P, Pairolero PC, Cherry KJ,Kazmier FJ. Recurrent aneurysms and late vascular compli-cations following repair of abdominal aortic aneurysms.Arch Surg 1985;120:590–4.
7. Crawford ES, Saleh SA, Babb JW, 3rd, Glaeser DH, VaccaroPS, Silvers A. Infrarenal abdominal aortic aneurysm: factorsinfluencing survival after operation performed over a 25-year period. Ann Surg 1981;193:699–709.
8. Carrel T, Pasic M, Jenni R, Tkebuchava T, Turina MI.Reoperations after operation on the thoracic aorta: etiology,surgical techniques, and prevention. Ann Thorac Surg 1993;56:259–68.
9. Allen RC, Schneider J, Longenecker L, Smith RB, 3rd,Lumsden AB. Paraanastomotic aneurysms of the abdominalaorta. J Vasc Surg 1993;18:424–31.
0. Fox AD, Berkowitz HD. Thoracoabdominal aneurysm resec-tion after previous infrarenal abdominal aortic aneurysmec-tomy. Am J Surg 1991;162:142–4.
1. Curl GR, Faggioli GL, Stella A, D’Addato M, Ricotta JJ.Aneurysmal change at or above the proximal anastomosisafter infrarenal aortic grafting. J Vasc Surg 1992;16:855–9.
2. Edwards JM, Teefey SA, Zierler RE, Kohler TR. Intraabdomi-nal paraanastomotic aneurysms after aortic bypass grafting.J Vasc Surg 1992;15:344–50.
3. Biglioli P, Roberto M, Cannata A, et al. Upper and lowerspinal cord blood supply: the continuity of the anteriorspinal artery and the relevance of the lumbar arteries.J Thorac Cardiovasc Surg 2004;127:1188–92.
4. Gloviczki P, Pairolero P, Welch T, et al. Multiple aorticaneurysms: the results of surgical management. J Vasc Surg1990;11:19–27.
5. Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ.Experience with 1509 patients undergoing thoracoabdomi-nal aortic operations. J Vasc Surg 1993;17:357–68.
6. Bauer M, Bauer U, Siniawski H, Hetzer R. Differences inclinical manifestations in patients with bicuspid and tricus-pid aortic valves undergoing surgery of the aortic valveand/or ascending aorta. Thorac Cardiovasc Surg 2007;55:485–90.
7. Etz CD, Homann TM, Luehr M, et al. Spinal cord blood flowand ischemic injury after experimental sacrifice of thoracicand abdominal segmental arteries. Eur J Cardiothorac Surg2008;33:1030–8.
8. Etz CD, Di Luozzo G, Zoli S, et al. Direct spinal cordperfusion pressure monitoring in extensive distal aorticaneurysm repair. Ann Thorac Surg 2009;87:1764–73.
9. Kouchoukos NT, Masetti P, Rokkas CK, Murphy SF, Black-stone EH. Safety and efficacy of hypothermic cardiopulmo-nary bypass and circulatory arrest for operations on thedescending thoracic and thoracoabdominal aorta. Ann Tho-rac Surg 2001;72:699–707.
0. Kouchoukos NT, Masetti P, Rokkas CK, Murphy SF. Hypo-thermic cardiopulmonary bypass and circulatory arrest foroperations on the descending thoracic and thoracoabdomi-nal aorta. Ann Thorac Surg 2002;74:S1885–7.
1. Kouchoukos NT, Masetti P, Murphy SF. Hypothermic car-diopulmonary bypass and circulatory arrest in the manage-ment of extensive thoracic and thoracoabdominal aortic
aneurysms. Semin Thorac Cardiovasc Surg 2003;15:333–9.
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R JOSEPH S. COSELLI (Houston, TX): Very nicely presented,nd very interesting and provocative data. Congratulations onetting excellent results in an extremely difficult group of pa-ients. But what are your current thoughts about this reoperativeroup and the primary group with regard to intercostal arteryeattachment?
R ETZ: Our strategy since 1993 has been—and continues toe—not to reattach segmental arteries. We use MEP monitoringnd CSF drainage in pretty much all patients except for a few inhom it is technically very difficult. And we believe that seg-ental artery reattachment is not necessary.It seems as though in this specific patient cohort, spinal cord
erfusion has had some priming, or there is some compensationhich takes place after the primary procedure, because we see
hat paraplegia rates in the redo patients are lower than inomparable primary procedures: that has been shown by yourroup, I think, and by Dr Kouchoukos as well. The low paraple-ia rate in our redo cases underscores the success of theonreattachment strategy.
R COSELLI: We found in our own work that patients under-oing redo operations certainly had no increased risk of para-legia. Although the results for this group were not statisticallyignificantly different, the redo patients’ risk was numericallyctually somewhat less than that of the primary patients.
R YUTAKA OKITA (Kobe, Japan): The left lung is always aroblem in this kind of cohort. So how many patients did youave with chronic obstructive lung disease preoperatively? Andow often do you have endobronchial bleeding especially in theatients who have hypothermic circulatory arrest? And how doou prevent lung complication during operation?
R ETZ: In this cohort there were 8 patients who presented withhronic obstructive pulmonary disease, about 15%. The risk ofndobronchial bleeding certainly is a major concern, and this isn partly why we advocate the 2-day procedure for patients inhom extensive manipulation of the lung is required and a
evere problem with pulmonary secretions often develops. Thextra day allows time for extensive suctioning of the lung and forleeding to subside. Otherwise, other than really careful han-ling, there is not much I can recommend.
R PETER T. MORTENSEN (Copenhagen, Denmark): Congrat-lations with your results on a very sick patient population Iust say. It was very nice that you compared your patient groupith a background population of New York. But what would beore interesting, at least to me, is to see what would have
appened if you did not operate on this patient group. Wouldou have any comments on the foreseeing events for theseatients if you had not operated on them.
R ETZ: This is another difficult question that revolves aroundhe issue of what is the optimal diameter at which to operate onatients with thoracic aneurysms. The average diameter in thisohort was 7 cm, including the dissections. It was even a littleigher in the patients who did not have a dissection. I cannotnswer from the data we have, since our computed tomography
can follow-up includes few patients with aneurysms larger than tcm because that is beyond the threshold at which we wouldoutinely recommend operation. We suspect from natural his-ory studies that the mortality rate would have been muchigher in these patients if we had not operated.
R ERIC E. ROSELLI (Cleveland, OH): I agree. I think you’dave a lot more dead people than live ones. Congratulations ongreat presentation and great experience.I wasn’t surprised to see that folks who had the clamp-and-
ew technique had a higher risk of adverse events. But I thoughthat it was interesting to note that the folks with deep circulatoryrrest seemed to be different than the others. And I think thatene Blackstone would say that we’d have to probably look
loser at that bias for making a choice of using that technique toetermine the propensity of undergoing circulatory arrest. Doou have some sense or can you give us some idea how youhoose circulatory arrest over partial bypass or left heart bypassn this group?
R ETZ: I would agree that it is certainly a valid concern that theroups having repair with different techniques might not beomparable. We felt reasonably comfortable with the conclu-ions from this study because there were generally very sickatients in the HCA group: it includes patients with unclamp-ble aortas, and with more severe atherosclerotic disease. In Dr.oselli’s group, HCA was used in a very high percentage ofrgent and emergent procedures, I think 51%. The proportion ofrgent and emergent procedures was not as high in our group.evertheless, the HCA patients were high risk patients as
ompared with the LHB and partial cardiopulmonary bypassatients, although the selection of technique was based on
echnical factors rather than on risk profile.
R CHRIS ROKKAS (Athens, Greece): My question relates tohe management of the airway, do you use a double-lumenndotracheal tube in all your cases? We have found that the leftung should stay deflated the entire time and only be reinflatedfter administration of protamine. This decreases the incidencef intraparenchymal hematomas. I wonder whether you have aolicy regarding the state of inflation of the lung for thisrocedure.
R ETZ: We use double lumen intubation in all patients as well.uring DHCA there is usually no reinflation of the lungs. The
-day procedure in part is an attempt to address this issue: toave the ability to reinflate the lungs and clear the secretions.ut there is no protocol as far as I know. We inflate the lungshenever the technical progression of the procedure allows it.
R JOSEPH E. BAVARIA (Philadelphia, PA): A follow-upomment: if we’re doing redo thoracic aortic surgery or redohoracoabdominal, on patients with FEV1 less than 60%, we uselective “on-the-table” tracheostomy just for the airway. Do youave any policy like that?
R ETZ: Doctor Griepp is a proponent of early tracheostomyith any respiratory complication, but there is no protocol forrospective elective tracheostomy. We do it early postopera-
ively if there is any problem.
