Is Conventional Open Repair Still a Good Option for Aortic Arch Aneurysm in Patients of Advanced Age?

doi:10.1016/j.athoracsur.2015.06.064

The Annals of Thoracic Surgery

Volume 101, Issue 1, January 2016, Pages 80-86

Presented at the Poster Session of the Fifty-first Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 24–28, 2015.

https://doi.org/10.1016/j.athoracsur.2015.06.064 Get rights and content

Background

Although thoracic endovascular aortic repair has advantages in elderly patients, it is not always applicable, and some elderly patients require open surgical repair.

Methods

Between 2008 and 2014, 157 patients (11 men) older then 75 years (mean age, 79.3 ± 3.3 years) underwent conventional total arch replacement, of which 39 were emergency operations. Coexisting diseases included remote stroke in 54 patients, coronary artery disease in 64, chronic obstructive pulmonary disease in 25, and chronic kidney disease in 112. Concomitant procedures were performed in 46 patients.

Results

Mean follow-up time was 2.9 ± 1.8 years. Mean cardiopulmonary bypass time was 251.1 ± 68.4 minutes. Mean lowest nasopharyngeal temperature was 23.2° ± 3.4°C. The hospital mortality rate was 7.6% (12 of 157) overall, 5.1% in elective cases, and 15.4% in emergency cases. Postoperative complications included permanent neurologic dysfunction in 5.7% of patients and prolonged ventilation time exceeding 72 hours in 13.4%. No spinal cord complications occurred. The 1-year and 5-year survival rates were 88.2% and 69.2% in all cases and 91.3% and 77.0% in elective cases, respectively. Univariate analysis demonstrated that risk factors for hospital death in elective cases were chronic kidney disease (odds ratio, 4.00; p = 0.028) and ventilation time exceeding 72 hours (odds ratio, 13.3; p = 0.001).

Conclusions

Even in patients older than 75 years, recent surgical results of conventional open arch repair were acceptable, especially in elective cases. Thus, conventional open surgical aortic arch replacement remains a good option, especially in patients with preserved renal function.

Section snippets

Patients

From January 2008 to April 2014, 157 patients (111 men) older than 75 years underwent conventional TAR (mean age, 79.3 ± 3.3 years; range, 75 to 92 years). Figure 1 shows patient distribution by age. There were 39 emergency operations for acute aortic dissection type A in 24 patients, acute aortic dissection type B in 2, and rupture of arch aneurysm in 13. Perioperative comorbidities included remote stroke in 53 patients, coronary artery disease in 64, chronic obstructive pulmonary disease in

Results

The mean operation time was 452 ± 132 minutes, mean cardiopulmonary bypass time was 251 ± 68 minutes, mean cardiac arrest time was 148 ± 47 minutes, and mean lower body circulatory arrest time was 63 ± 15 minutes. The mean lowest nasopharyngeal temperature was 23.2° ± 3.4°C.

The hospital mortality rate was 7.6% (12 of 157) overall, 5.1% (6 of 118) in elective cases, 15.4% (6 of 39) in emergency cases, and 3.9% (3 of 76) in elective cases without a concomitant operation (Table 2). The causes of

Comment

Recent advances in brain protection, surgical techniques, anesthesia, and critical care have improved surgical outcomes of conventional TAR [1]. A recent case series has reported mortality rates of 4% to 8% 2, 3, 4, 5, 6, 7, 8, 9. Although the recent surgical results are better than those reported a decade ago, this operation is a still challenge, especially in elderly patients. Aging causes a decline in organ function and leads to more aortic atherosclerosis. However, conventional TAR could

References (20)

H. Ogino et al.
Evolving arch surgery using integrated antegrade selective cerebral perfusion: impact of axillary artery perfusion
J Thorac Cardiovasc Surg
(2008)
M.E. Halkos et al.
Selective antegrade cerebral perfusion via right axillary artery cannulation reduces morbidity and mortality after proximal aortic surgery
J Thorac Cardiovasc Surg
(2009)
H.J. Patel et al.
Open arch reconstruction in the endovascular era: analysis of 721 patients over 17 years
J Thorac Cardiovasc Surg
(2011)
K. Okada et al.
Recent advancements of total aortic arch replacement
J Thorac Cardiovasc Surg
(2012)
M. Shiono et al.
Emergency surgery for acute type A aortic dissection in octogenarians
Ann Thorac Surg
(2006)
W. Hogendoorn et al.
Thoracic endovascular aortic repair with the chimney graft technique
J Vasc Surg
(2013)
A. Zierer et al.
Antegrade cerebral perfusion with mild hypothermia for aortic arch replacement: single-center experience in 245 consecutive patients
Ann Thorac Surg
(2011)
K. Minatoya et al.
Surgical management of distal arch aneurysm: another approach with improved results
Ann Thorac Surg
(2006)
N. Shiiya
Aortic arch replacement for degenerative aneurysms: advances during the last decade
Gen Thorac Cardiovasc Surg
(2013)
M. Masuda et al.
Thoracic and cardiovascular surgery in Japan during 2012
Gen Thorac Cardiovasc Surg
(2014)

There are more references available in the full text version of this article.

Cited by (8)

Single-Stage Hybrid Aortic Arch Repair is Associated With a Lower Incidence of Postoperative Acute Kidney Injury Than Conventional Aortic Surgery
2019, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
The authors’ findings showed that the CPB duration was much shorter in patients who underwent HAR than in those who underwent CTAR, which was in accordance with the findings of previous studies.16,19 A long CPB duration was identified as an independent risk factor for postoperative AKI, as previously demonstrated.9 An early study conducted by Svensson and colleagues29 found that the mortality rate was markedly increased after 65 minutes of circulatory arrest and that CPB time was a predictor of early death.
The authors compared the renal outcomes of single-stage hybrid aortic arch repair without deep hypothermic circulatory arrest versus conventional total arch replacement in management of thoracic aortic diseases.
A retrospective review from January 2013 to December 2016 in Fuwai Hospital of 757 consecutive patients who underwent aortic arch repair: conventional total arch replacement (CTAR, 651), and hybrid arch repair (HAR, 106), with propensity matching (95 pairs).
The primary end-point was postoperative acute kidney injury (AKI) defined using the Kidney Disease Improving Global Outcome criteria. The secondary end-point was short-term outcomes such as in-hospital mortality and paraplegia determined by the Society of Thoracic Surgeons. The patients in the HAR group were older (60.20 ± 9.95 v 46.43 ± 10.79, p < 0.0001) and exhibited a greater rate of diabetes (11.3% v 2.0%, p = 0.0004), hyperlipidemia (47.2% v 25.4%, p < 0.0001), and coronary artery disease (13.2% v 4.3%, p < 0.0001) than those in the CTAR group. Following propensity score matching of 95 matched pairs, the difference in preoperative risk diminished. The HAR group led to a shorter cardiopulmonary bypass time (133.33 ± 41.47 v 179.62 ± 40.79, p < 0.0001) and avoided circulatory arrest. The incidence of postoperative AKI between HAR and CTAR groups was significantly different (before match: 75.5% v 59.45%, p = 0.0046; after match: 78.9% v 57.9%, p = 0.0008).
In the management of thoracic aortic diseases, HAR is associated with a significantly lower incidence of postoperative AKI, and showed equivalent short-term outcomes despite the older age compared with the CTAR group.
Conventional Open Versus Hybrid Arch Repair of Aortic Arch Disease: Early and Long-Term Outcomes
2019, Annals of Thoracic Surgery
Citation Excerpt :
The HAR group herein showed a higher incidence of perioperative stroke by comparison (TAR: 2.9%; HAR: 12.5%; p = 0.004). This outstanding result is also consistent with other data released in the past few years [3, 4]. In a meta-analysis of 21 reports published from 2004 to 2014, Settepani and colleagues [3] emphasized that outcomes of TAR in the modern era have dramatically improved (stroke, 3.4%).
It is unclear at present whether conventional open repair or a hybrid technique is preferential in the treatment of aortic arch diseases. Our intent was to compare early and long-term outcomes of both therapeutic strategies.
Between January 2002 and December 2017, 238 patients eligible for total arch replacement (TAR; 174) or hybrid arch repair (HAR; 64) qualified for study. A retrospective analysis of clinical outcomes was undertaken, with propensity matching (48 pairs). Mean follow-up duration was 60.2 months.
In-hospital mortality rates were 4.6% (8 of 174 patients) and 6.3% (4 of 64 patients) in the TAR and HAR groups, respectively (p = 0.739). The TAR group displayed a lower incidence of permanent stroke (2.9%, 5 of 174 patients) by comparison (HAR: 12.5%, 8 of 64 patients; p = 0.004). Overall survival rates at 5 and 10 years differed significantly by group (TAR: 87.0% ± 5.5% and 81.9% ± 4.8%, respectively; HAR: 69.5% ± 7.4% and 40.8% ± 11.1%, respectively; p = 0.003). After propensity matching, in-hospital mortality (4.2% versus 4.2%, p > 0.99) and patient morbidities showed no statistically significant group differences. For patients undergoing HAR, a tendency for permanent stroke (14.5% versus 2.1%, p = 0.070) was evident. In the TAR (versus HAR) group, 10-year overall survival (74.7% versus 42.6%, p = 0.043) and reintervention-free (93.2% versus 34.0%, p < 0.001) rates were significantly better.
In the treatment of aortic arch diseases, HAR showed equivalent short-term outcomes compared with TAR but was limited regarding long-term outcomes beyond 5 years after the procedure. Conventional TAR remains the gold standard of therapy, and our findings suggest that the hybrid approach should be reserved for strictly selected patients with significant comorbidities.
Distal Arch Aneurysm Repair Using Left Subclavian Artery Transposition With Stented Elephant Trunk in the Hybrid Repair Era
2019, Heart Lung and Circulation
Citation Excerpt :
Open surgery continues to be the gold standard for surgical treatment of aortic disease involving the aortic arch and descending aorta. Even in older patients, open surgery for aortic arch lesions obtained satisfactory surgical results [18,19]. In a cohort of 157 patients older than 75 years who underwent conventional total arch replacement, the in-hospital mortality rate was 7.6% (12 of 157).
Hybrid aortic arch repair is an invasive approach to the surgical management of distal aortic arch aneurysm. The complications associated with hybrid aortic arch repair, such as stroke and endoleaks, are not uncommon and late reintervention is frequent. We retrospectively reviewed our experience of distal aortic arch aneurysm repair using the stented elephant trunk procedure with left subclavian artery (LSCA)-left common carotid artery (LCCA) transposition in the hybrid repair era.
Between May 2009 and September 2016, 19 patients with distal aortic arch aneurysm underwent LSCA-LCCA transposition with stented elephant trunk implantation under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion. All patients were males with a median age of 51 ± 14 (range 20–69) years.
There were no in-hospital deaths. Continuous renal replacement therapy was not required in patients with preoperative renal dysfunction after surgery. No neurologic deficits were observed in any patients prior to hospital discharge. One patient underwent concomitant thoracic endovascular aortic repair after this technique. One case required reoperation due to bleeding. One patient required debridement due to poor wound healing. During a mean follow-up of 33 ± 21 months, one patient died.
Satisfactory results were obtained in suitable patients undergoing surgery for distal aortic arch aneurysm using LSCA-LCCA transposition with stented elephant trunk implantation in the hybrid repair era. The straightforward nature of the surgical approach, with avoidance of the complications related to hybrid aortic arch repair and reduction of late re-intervention favours this technique for treating distal aortic arch aneurysm.
Surgical Repair of Distal Aortic Arch Aneurysm With Distal Extension: Sternotomy Versus Thoracotomy
2019, Annals of Thoracic Surgery
Citation Excerpt :
In the present study, the sternotomy group had outcomes in terms of perioperative stroke (OR 6.83, p < 0.01). This outstanding result was consistent with recent outcomes of reports from the last few years [12–14]. A meta-analysis from Fabrizio and colleagues [12] that included 21 reports published between 2004 and 2014, they reported that the outcomes of total arch replacement in the modern era dramatically improved (stroke, 3.4%).
There is no consensus as to whether a median approach or a lateral approach is better for distal aortic arch aneurysms with distal extensions. The aim of this study was to compare clinical outcomes of these two approaches for distal aortic arch aneurysms with distal extensions.
From January 2001 to December 2017, 212 consecutive patients with distal aortic arch aneurysms with distal extensions underwent surgery using different approaches: hemiarch and descending thoracic aneurysm replacement through thoracotomy (group 1, n = 91); and total arch and descending thoracic aneurysm replacement through sternotomy (group 2, n = 121). Early and late outcomes were compared using scores and inverse probability of treatment adjustments to reduce treatment selection bias.
The in-hospital mortality was 9.89% (9 of 91) in the thoracotomy group and 2.48% (3 of 121) in the sternotomy group (p = 0.02). The sternotomy group had a lower incidence of permanent stroke (2.48%, 3 of 121) compared with the thoracotomy group (10.99%, 10 of 91, p = 0.01). After adjustment, patients who underwent thoracotomy were at a greater risk of hospital mortality (odds ratio 5.0, p = 0.01), permanent stroke (odds ratio 6.83, p < 0.01), and pneumonia (odds ratio 2.99, p = 0.04), compared with patients who underwent sternotomy. The overall survival at 10 years was 69.8% ± 7.0% for the thoracotomy group and 83.0% ± 5.0% for the sternotomy group (unadjusted p = 0.049, adjusted p = 0.034).
The sternotomy approach showed better outcomes in terms of operative mortality, stroke, and pneumonia, as well as long-term survival compared with the thoracotomy approach. These results suggested that the sternotomy approach was more appropriate for patients with distal aortic arch aneurysms with distal extensions.
A Challenging Treatment for Aortic Arch Aneurysm With Fenestrated Stent Graft
2017, Annals of Thoracic Surgery
Citation Excerpt :
According to a recent report, the outcome of traditional open surgery for AAA is improving. The incidence of morbidity and mortality after AAA repair with brain perfusion and cardiopulmonary bypass, which differs according to operative methods, ranges from 4.6% to 10.0% [6–8]. In our institution, open surgery was also the treatment of choice for AAA.
The endovascular stent graft is a novel therapeutic technique that is used in the treatment of aortic aneurysms. However, the aortic arch is a still an area that requires endovascular repair. Since 2008, the authors have treated aortic arch aneurysms (AAA) in patients without an extraanatomical bypass using a fenestrated stent graft (FSG). This study aimed to evaluate the early outcomes of FSG treatment.
The authors retrospectively investigated the early outcomes of 54 AAA cases that were performed in their department from January 2008 to May 2016. The early results were analyzed retrospectively.
The primary technical success rate was 100%. There were 2 operative deaths due to shower embolism and respiratory failure (2 of 54, 3.7%). Two patients suffered central nervous system injury (2 of 54, 3.7%) without remaining sequelae. At a mean follow-up period of 41.4 months, the survival rate was 75.0% and there were no aortic-related deaths. On follow-up, secondary intervention was necessary in 3 cases. The rate of freedom from secondary reintervention was 92.5%.
Although further observation and prospective studies involving larger numbers of patients will be needed to validate this process, the outcomes of FSG treatment and our procedures were acceptable. This procedure has the potential to expand the indications for treatment in patients with AAA that are deemed to be suitable for this treatment.
Advanced Age Is a Risk Factor in Aortic Arch Surgery
2017, Annals of Thoracic Surgery

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Original articleAdult cardiacIs Conventional Open Repair Still a Good Option for Aortic Arch Aneurysm in Patients of Advanced Age?

Background

Methods

Results

Conclusions

Section snippets

Patients

Results

Comment

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Vasc Surg

Antegrade cerebral perfusion with mild hypothermia for aortic arch replacement: single-center experience in 245 consecutive patients

Ann Thorac Surg

Surgical management of distal arch aneurysm: another approach with improved results

Ann Thorac Surg

Aortic arch replacement for degenerative aneurysms: advances during the last decade

Gen Thorac Cardiovasc Surg

Thoracic and cardiovascular surgery in Japan during 2012

Gen Thorac Cardiovasc Surg

Original article
Adult cardiac
Is Conventional Open Repair Still a Good Option for Aortic Arch Aneurysm in Patients of Advanced Age?