Mid-term Outcomes of Open Thoracoabdominal Aortic Aneurysm Repair Following Thoracic Endovascular Aortic Repair

The aim of this study was to evaluate the safety and durability of open repair in patients with thoracoabdominal aortic aneurysm (TAAA) after thoracic endovascular aortic repair (TEVAR). Data were analyzed for 65 patients (20 men; 30.8%) undergoing open TAAA repair (TAAAR) at a median of 2.6 years after TEVAR. Outcomes were compared between patients with and without Marfan syndrome (MFS) (n = 39; 60%). Mean age at TAAAR was 41 ± 11 years. Before TAAAR, 27 patients (41.5%) underwent re-TEVAR. Type I endoleak was seen in 21 patients (32.3%), type II endoleak in 4 (6.2%), patent false lumen in 38 (58.5%), aortic rupture in 10 (15.4%), and graft infection in 2 (3.1%). TAAAs were Crawford extent I in 10 (15.4%), II in 23 (35.4%), III in 23 (35.4%), and IV in 9 (13.8%). Maximal TAA size was 72 ± 22 mm (Table). Emergent TAAAR was done in 11 (16.9%). Femoro-femoral bypass was used in 36 (55.4%) and circulatory arrest in 23 (35.4%). Endograft was explanted in 33 (50.8%). Stroke, paraplegia, and acute kidney injury occurred in five (7.7%), seven (10.8%), and seven (10.8%) patients, respectively. Operative mortality was 16.9% (11/65), due to stroke (n = 5), respiratory failure (n = 2), bowel necrosis (n = 1), low cardiac output (n = 1), and coagulopathy (n = 2). Endograft extraction was predictive of operative death (odds ratio, 5.63; 95% confidence interval, 1.11-28.52; P = .037). Clinical and computed tomography follow-up was complete in 100% (54/54) at a mean of 3.1 ± 1.4 years. Branch vessel events occurred in 11 patients at a median of 10 months (range, 0.4-18.3), including intercostal atrial (IA) dilation in six, IA stenosis in three, and iliac stenosis in one, exclusively seen in MFS (32.4% [11/34] vs 0; P = .004). Aortic graft infection occurred in two patients at 0.4 and 3.7 years, respectively; one died and one survived after medical therapy. Ascending aortic + total arch repair was done for retrograde type A dissection in two patients at 2.5 and 1.3 years, respectively. Late death occurred in four patients at 1.9 ± 1.7 years from aortotracheal fistula in two, and sepsis and stroke in one each. At 5 years, survival and freedom from reoperation were 73.6% and 95.7%, respectively, which did not differ significantly between MFS and non-MFS patients (P = .084 and P = .465, respectively). In this series of thoracoabdominal aortic aneurysm after TEVAR, open repair was safe and achieved favorable early and midterm outcomes. Endograft extraction predicted early mortality risk. Although not at increased risk of mortality and late reoperation, patients with MFS are prone to developing branch vessel dilation/stenosis early after open TAAAR.TablePatient profile, operative data, and late outcomes of thoracoabdominal aortic aneurysm repair (TAAAR) after thoracic endovascular aneurysm repair (TEVAR)VariableWhole series (n = 65)MFSP valueYes (n = 39)No (n = 26)Baseline characteristics Age, years41 ± 1134 ± 752 ± 8<.001 Male gender20 (30.8)18 (46.2)2 (7.7).001 Body mass index >25 kg/m221 (32.3)8 (20.5)13 (50).017 Hypertension34 (52.3)11 (28.2)23 (88.5).000 Smoking23 (35.4)8 (20.5)15 (57.7).003 Indications for prior TEVAR.001Type B aortic dissection43 (66.2)23 (59)20 (76.9)Type A aortic dissection18 (27.7)16 (41)2 (7.7)Penetrating aortic ulcer3 (4.6)0 (0)3 (11.5)Aortic rupture1 (1.5)0 (0)1 (3.8) Maximal proximal aortic size, mm30 ± 529 ± 431 ± 5.110 Maximal distal aortic size, mm72 ± 2266 ± 1580 ± 27.014Operative data Emergency repair11 (16.9)2 (5.1)9 (34.6).005 Distal perfusion strategy.019Simple aortic clamping9 (13.8)4 (10.3)5 (19.2).465Aorto-iliac bypass20 (30.8)17 (43.6)3 (11.5).007Femoro-femoral bypass36 (55.4)18 (46.2)18 (69.2).080Deep hypothermic circulatory arrest23 (35.4)9 (23.1)14 (53.8).017 Part or complete graft extraction33 (50.8)15 (38.5)18 (69.2).023 Clamp and ischemic times, minutesProximal aortic clamp time16 (0-21)17 (12-26)0 (0-17.5).026Intercostal artery38 (23-59)38 (21-57)39 (27-69).558Superior mesenteric artery33 (24-43)36 (24-45)28 (24-36).098Celiac artery, unprotected40 (30-57)45 (35-59)31 (25-39).006Maximal renal artery44 (35-52)45 (40-55)37.5 (28-46).008 Intercostal/lumbar artery reattachment52 (80)34 (87.2)18 (69.2).114 Reconstruction of subclavian artery15 (23.1)9 (23.1)6 (23.1)1.000 Reconstruction of right iliac artery37 (57.8)24 (61.5)13 (52).604 Cerebrospinal fluid drainage45 (69.2)31 (79.5)14 (53.8).053Early outcomes Operative mortality11 (16.9)5 (12.8)6 (23.1).325 Stroke5 (7.7)2 (5.1)3 (11.5).382 Paraplegia7 (10.8)2 (5.1)5 (19.2).106 Reoperation for bleeding8 (10.8)5 (11.6)3 (9.7)1.000 Acute kidney injury requiring dialysis7 (10.8)3 (7.7)4 (15.4).424 Pulmonary complications19 (29.2)7 (17.9)12 (46.2).025 Gastrointestinal dysfunction4 (6.2)2 (5.1)2 (7.7)1.000 Length of intensive care unit stay, days3.7 (1.7-5.6)3.5 (1.6-5.3)4.3 (2.4-7.1).090Late outcomes(n = 54, %)(n = 34, %)(n = 20, %) Follow-up duration, years3.1 ± 1.43.3 ± 1.32.7 ± 1.5.275 Late death4 (7.4)1 (2.9)3 (15).138 Late reoperation2 (3.7)2 (5.9)0 (0).525 Branch vessel dilation or stenosisa11 (20.4)11 (32.4)0 (0).004 5-year Kaplan-Meier survival, %73.6 (58.9-83.8)81.0 (59.7-91.7)61.5 (37.2-78.8).084 5-year freedom from reoperation, %95.7 (72.9-99.4)93.3 (61.3-99.0)100 (100).465MFS, Marfan syndrome; TAAAR, thoracoabdominal aortic aneurysm repair; TEVAR, thoracic endovascular aortic repair.Data are presented as mean ± standard deviation, median (interquartile range), number (%), or % (95% confidence interval).aRefers to aneurysmal dilation or stenosis (or occlusion) in abdominal aortic branches and the iliac arteries. 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