Outcomes in open repair of the thoracic and thoracoabdominal aorta
2010; Elsevier BV; Volume: 52; Issue: 4 Linguagem: Inglês
10.1016/j.jvs.2010.06.137
ISSN1097-6809
AutoresCharles W. Acher, Martha M. Wynn,
Tópico(s)Infectious Aortic and Vascular Conditions
ResumoThere has been a significant decrease in mortality and paraplegia risk during the last 25 years in the treatment of thoracic and thoracoabdominal aortic disease (Fig 1). The primary factors in this improvement have been the use of cerebrospinal fluid drainage and moderate to profound hypothermia, combined with optimizing arterial perfusion pressure and cardiac function and the use of neurochemical protection. Effective application of these critical concepts has resulted in a 75% to 80% reduction in paraplegia and a 50% reduction in mortality in most single-center reports where surgery is supported by a dedicated anesthesia and surgical team using treatment protocols that optimize these critical factors.1Fehrenbacher J.W. Hart D.W. Huddleston E. Siderys H. Rice C. Optimal end-organ protection for thoracic and thoracoabdominal aortic aneurysm repair using deep hypothermic circulatory arrest.Ann Thorac Surg. 2007; 83: 1041-1046Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 2Jacobs M.J. Elenbaas T.W. Schurink G.W. Mess W.H. Mochtar B. Assessment of spinal cord integrity during thoracoabdominal aortic aneurysm repair.Ann Thorac Surg. 2002; 74 (discussion S92-8): S1864-S1866Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar, 3Conrad M.F. Cambria R.P. Contemporary management of descending thoracic and thoracoabdominal aortic aneurysms: endovascular versus open.Circulation. 2008; 117: 841-852Crossref PubMed Scopus (65) Google Scholar, 4Acher C. Wynn M. Naloxone and spinal fluid drainage as adjuncts in the surgical treatment of thoracoabdominal aneurysms.Surgery. 1990; 108: 755-762PubMed Google Scholar However, there is still considerable variation in mortality and paraplegia rates in clinical reports, with little understanding of the causes of this variation in outcomes (Table I).Table IMortality, paraplegia, and combined morbidity outcomes in surgical reports using predictive models to generate observed/expected (O/E) ratios to compare techniques of repair and protective adjuncts. O/E Morb is observed combined mortality and paraplegia divided by estimated mortality and paraplegiaYearSeriesTechniqueC1C2C3C4TADeficit O/EPts (No.)Def (%)Mort (%)Acute (%)O/E MortO/E Morb1987KazuiAC14811.32952.1114.710.53.292.7741988CunninghamAC52234.423016.6720.03.37.615.7351988VaccaroXCL39881.202817.8625.025.01.701.4481988MayoXCL152020460.651014.9514.91.04.681.8391988DavidsonEPIDC22310.0080.000.012.50.000.0001989KeiferAC310183111.474520.004.42.20.761.2571989SvenssonAC374.461050.0020.010.02.553.6761989SvenssonXCL13149.76944.4444.40.026.3714.2421989SvenssonXCL+SFD12341.451010.0010.00.03.922.1161989PokelaAC33110.41175.885.929.40.360.3841989CambriaXCL12820150.61557.2734.518.23.091.8051989MurrayAC1546230.69488.3312.56.31.841.0991989MurrayXCL+SFD81417110.63508.0012.06.01.741.0251990Acher-WynnXCL485341.032425.008.337.50.370.8181990Acher-WynnXCL+SFDN585320.17234.358.747.80.320.2461990de MolAC3830.851421.4321.40.02.281.2341990SchmidtXCL2132230.494010.0012.542.50.540.5131990CrawfordXCL2392932612690.98106213.1810.04.71.481.1461991WilliamsAC1514111.464025.0022.52.53.101.9481991CrawfordAC598536301.1421020.002.94.80.350.8871991LordXCL1271.331921.0531.65.34.052.2321991FoxXCL24271.875113.7327.515.73.222.5981992HollierXCL221623470.711085.567.41.92.061.1321992HollierXCL+SFD7131660.00420.0016.72.43.311.0241992CoxXCL103740421.0112919.3834.941.91.541.2991992GoldenXCL5912312.105717.5417.58.82.772.3851993WilliamsAC+SFD670.21137.690.07.70.000.1441993CrawfordXCL3784423433461.00150915.518.26.60.990.9961993NajafiAC53230.52316.456.59.70.790.6291994SafiAC+SFD14310.28458.894.46.70.310.2891994SafiAC73391.2611227.689.85.40.971.1691994FrankAC+SFD393140.00200.0010.05.01.330.4381994AcherXCL+SFDN919615120.14613.283.341.00.140.1411994KeifferHCA34140.27128.3333.38.32.310.9221994MayoXCL452368700.922069.2221.814.62.401.6251994BorstAC211111.351324.559.810.61.901.6831994Svenson-CoselliAC44541.319831.634.11.00.441.0661994JanuszAC1732080.34484.1714.620.81.190.7591994CoselliXCL1379573670.343726.455.414.50.440.3791994GallaAC55160.952611.5415.411.51.761.2871995SafiAC+SFD31630.33948.519.62.10.920.4971995SafiAC25170.904219.0514.39.51.261.0241995Gilling-SmithXCL+SFD202918630.561307.6927.715.42.581.4531995ShiiyaAC36391.182123.814.80.00.641.0331995KouchoukosHCA13136190.38515.889.80.01.710.7401998KouchoukosHCA21217470.25963.135.20.01.110.4821995ComerataAC+SFD43530.36156.676.740.00.310.3301995BavariaXCL1261891.513625.0022.236.11.141.3121995BavariaAC14127120.47454.444.40.01.270.6841995HollierAC+SFD407478730.452654.537.90.02.150.9121995PokelaAFB761310.542711.1122.225.91.290.8811996FehrenbacherAC11120.18234.354.330.40.220.1981996GrabitzXCL68815924280.8326015.0014.214.61.180.9691996CambriaEPIDC25122590.17712.829.98.51.070.4921996Acher-WynnXCL+SFDN24502133220.171503.335.335.30.260.2201996Acher-WynnXCL1017813190.946717.9116.453.70.610.7471996GrieppAC186715921.041387.9718.19.42.871.8661996Griepp1Fehrenbacher J.W. Hart D.W. Huddleston E. Siderys H. Rice C. Optimal end-organ protection for thoracic and thoracoabdominal aortic aneurysm repair using deep hypothermic circulatory arrest.Ann Thorac Surg. 2007; 83: 1041-1046Abstract Full Text Full Text PDF PubMed Scopus (54) Google ScholarHCA20749550.48955.2610.59.51.400.8581996BachetHCA112750.654320.9337.24.72.751.2771996HarwardXCL277131.362910.3417.20.06.112.6421996MauneyXCL10141014431.00919.8913.29.91.801.3401997SvennsonAC1151.151643.750.00.00.000.8381997SvennsonAC+SFD1340.361711.760.00.00.000.2611997JacobAC1412340.723312.1215.20.02.441.1881997OkitaHCA84130.23254.000.00.00.000.1651997CambriaEPIDC512455300.451606.889.410.01.000.6581997CoselliXCL25420912014000.427235.535.111.10.570.4781997SafiAC+SFD1041182840530.443439.6213.114.60.980.6471998SvennsonAC2490.753327.276.133.30.240.5381998SAFIAC+SFD110116380.5526412.5012.17.61.080.7242000CambriaEPIDC5330667140.451707.069.420.00.710.5672001KouchoukosHCA343725650.141612.486.210.60.580.3002001CoselliAC+SFD65800.281457.597.66.90.610.3872002CambriaEPIDC9259120660.5933711.288.324.30.520.5562002KouchoukosHCA+SFD374532780.151922.606.810.40.670.3462002CoselliAC+SFD5805732913290.2317734.467.711.60.680.4012003JacobAC+SFD6895250.141882.6610.63.71.230.4722003SafiAC+SFD2132051331941600.219053.9815.812.01.360.6422004CoselliXCL+SFD3870.503872.584.412.90.660.5862005JacobAC+SFD42700.221124.4613.44.51.440.5952006GreippAC+SFD411386320.121002.006.010.00.620.3122007CambriaEPIDC121691641010.7145512.978.620.00.600.6612007FehrenbacherHCA+SFD27492014630.181732.314.08.10.520.3072007CoselliAC+SFD7067623914270.2222863.816.65.20.770.3972007Acher-WynnXCL+SFDN92153941501080.185973.186.732.00.360.2722007Acher-WynnXCL+SFDN+IRP2520841300.051240.813.227.40.200.1242010Acher-WynnXCL+SFDN941651221981710.187503.336.434.90.320.2532010Acher-WynnXCL+SFDN+IRP29423270880.112611.923.832.60.210.158AC, Assisted circulation (atrial femoral or femoral-femoral bypass); C, Crawford type; HCA, hypothermic arrest; IR, intercostal reimplantation; SFD, spinal fluid drainage; SFDN, SFD and naloxone; TA, descending thoracic aneurysm; XCL, clamp and sew. Open table in a new tab AC, Assisted circulation (atrial femoral or femoral-femoral bypass); C, Crawford type; HCA, hypothermic arrest; IR, intercostal reimplantation; SFD, spinal fluid drainage; SFDN, SFD and naloxone; TA, descending thoracic aneurysm; XCL, clamp and sew. This report will attempt to explain this variation and identify some of the factors associated with mortality, paraplegia, renal failure, and long-term functional outcome. To accomplish this, a paraplegia risk model based on the extent of aortic replacement (Crawford classification) and clinical presentation (acute and dissection),5Acher C.W. Wynn M.M. Hoch J.R. Popic P. Archibald J. Turnipseed W.D. Combined use of cerebral spinal fluid drainage and naloxone reduces the risk of paraplegia in thoracoabdominal aneurysm repair.J Vasc Surg. 1994; 19 (discussion 247-8): 236-246Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar and a mortality risk model to compare risk from published reports are used to analyze results from clinical reports. The mortality risk model is based on the proportion of acute patients and the predicted number of paraplegias multiplied by a risk coefficient of 0.3 (the coefficient with the highest R2 value and approximates the mean acute and paraplegia associated mortality). This mortality model accounts for 76% of the variation between reports (Fig 2). The data for this analysis come from our own prospectively maintained database, which now includes 771 patients, and a database of approximately 100 publications reporting outcomes in >15,000 patients that we have maintained during the last 25 years. In our own patients we have prospectively measured cardiac index as a measure of cardiac function before, during, and after aortic cross-clamp and estimated glomerular filtration rate before surgery and up to 60 days after surgery, as well as other physiologic variables. Although mortality rates have improved over time in single-center reports, repair of these aneurysms is still recognized as high risk, with elective mortality and paraplegia rates >20% in reports using national and regional databases.6Cowan Jr, J.A. Dimick J.B. Henke P.K. Huber T.S. Stanley J.C. Upchurch Jr, G.R. Surgical treatment of intact thoracoabdominal aortic aneurysms in the United States: hospital and surgeon volume-related outcomes.J Vasc Surg. 2003; 37: 1169-1174Abstract Full Text Full Text PDF PubMed Scopus (302) Google Scholar, 7Rigberg D.A. McGory M.L. Zingmond D.S. Maggard M.A. Agustin M. Lawrence P.F. et al.Thirty-day mortality statistics underestimate the risk of repair of thoracoabdominal aortic aneurysms: a statewide experience.J Vasc Surg. 2006; 43 (discussion 223): 217-222Abstract Full Text Full Text PDF PubMed Scopus (262) Google Scholar In the report by Rigberg et al7Rigberg D.A. McGory M.L. Zingmond D.S. Maggard M.A. Agustin M. Lawrence P.F. et al.Thirty-day mortality statistics underestimate the risk of repair of thoracoabdominal aortic aneurysms: a statewide experience.J Vasc Surg. 2006; 43 (discussion 223): 217-222Abstract Full Text Full Text PDF PubMed Scopus (262) Google Scholar from California's statewide database, 30-day and 1-year mortality (elective and ruptured) was stratified by age, with an elective mortality of 19% at 30 days and 31% at 1 year, varying at 1 year from 18% for ages 50 to 59 years to 40% for 80 to 89 years. Ruptured mortality was 48% at 30 days and 62% at 1 year, with significant increases with age.7Rigberg D.A. McGory M.L. Zingmond D.S. Maggard M.A. Agustin M. Lawrence P.F. et al.Thirty-day mortality statistics underestimate the risk of repair of thoracoabdominal aortic aneurysms: a statewide experience.J Vasc Surg. 2006; 43 (discussion 223): 217-222Abstract Full Text Full Text PDF PubMed Scopus (262) Google Scholar The Cowan et al6Cowan Jr, J.A. Dimick J.B. Henke P.K. Huber T.S. Stanley J.C. Upchurch Jr, G.R. Surgical treatment of intact thoracoabdominal aortic aneurysms in the United States: hospital and surgeon volume-related outcomes.J Vasc Surg. 2003; 37: 1169-1174Abstract Full Text Full Text PDF PubMed Scopus (302) Google Scholar report looked nationally at elective mortality, which ranges from 15% in high-volume hospitals (5-31 per year) to 27% in low-volume hospitals (1-3 per year). Both reports concluded that higher volume was associated with lower mortality, whether by hospital or surgeon. The mean mortality rate in single-center reports is 12.5% (range, 0% to 44%). Adjusted for acuity and paraplegia, mortality observed/expected (O/E) ratios are a mean of 0.87 (range, 0 to 9.8). Since 1997, these mortality numbers have declined significantly to a mean mortality of 8.84% and mortality O/E ratio of 0.37 (Table I). Consistently, the most important factors for mortality in these reports are age, acuity, paraplegia, and decreased renal function.8Ergin M.A. Galla J.D. Lansman L. Quintana C. Bodian C. Griepp R.B. Hypothermic circulatory arrest in operations on the thoracic aorta Determinants of operative mortality and neurologic outcome.J Thorac Cardiovasc Surg. 1994; 107 (discussion 797-9): 788-797PubMed Google Scholar, 9Coselli J.S. LeMaire S.A. Miller 3rd, C.C. Schmittling Z.C. Koksoy C. Pagan J. et al.Mortality and paraplegia after thoracoabdominal aortic aneurysm repair: a risk factor analysis.Ann Thorac Surg. 2000; 69: 409-414Abstract Full Text Full Text PDF PubMed Scopus (276) Google Scholar, 10LeMaire S.A. Miller 3rd, C.C. Conklin L.D. Schmittling Z.C. Coselli J.S. Estimating group mortality and paraplegia rates after thoracoabdominal aortic aneurysm repair.Ann Thorac Surg. 2003; 75: 508-513Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 11Huynh T.T. van Eps R.G. Miller 3rd, C.C. Villa M.A. Estrera A.L. Azizzadeh A. et al.Glomerular filtration rate is superior to serum creatinine for prediction of mortality after thoracoabdominal aortic surgery.J Vasc Surg. 2005; 42: 206-212Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 12Kieffer E. Chiche L. Godet G. Koskas F. Bahnini A. Bertrand M. et al.Type IV thoracoabdominal aneurysm repair: predictors of postoperative mortality, spinal cord injury, and acute intestinal ischemia.Ann Vasc Surg. 2008; 22: 822-828Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar At the University of Wisconsin (UW), mortality for elective procedures is 3.1% and is 17.8% for acute patients, defined as rupture, contained rupture, acute dissection, mycotic aortitis, trauma, and acute plaque hemorrhage. In a multivariate model, the most important factors for operative mortality in our experience have been age, acute presentation, postoperative paraplegia, and poor renal function (serum creatinine >2 mg/dL; Table I). Factors significant on univariate analysis, such as transfusion volume, aortic occlusion time, cardiac index, and extent of aortic replacement were not significant in a larger multivariate model. Advanced age is a marker for comorbid conditions such as cardiac disease, chronic obstructive pulmonary disease, renal insufficiency, and advanced atherosclerosis that increase with age and are associated with higher treatment risk.13Kieffer E. Chiche L. Baron J.F. Godet G. Koskas F. Bahnini A. Coronary and carotid artery disease in patients with degenerative aneurysm of the descending thoracic or thoracoabdominal aorta: prevalence and impact on operative mortality.Ann Vasc Surg. 2002; 16: 679-684Abstract Full Text PDF PubMed Scopus (29) Google Scholar, 14Suzuki S. Davis 3rd, C.A. Miller 3rd, C.C. Huynh T.T. Estrera A.L. Porat E.E. et al.Cardiac function predicts mortality following thoracoabdominal and descending thoracic aortic aneurysm repair.Eur J Cardiothorac Surg. 2003; 24 (discussion 124): 119-124Crossref PubMed Scopus (28) Google Scholar, 15Crawford E.S. Crawford J.L. Safi H.J. Coselli J.S. Hess K.R. Brooks B. et al.Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients.Journal of Vascular Surgery. 1986; 3: 389-404Crossref PubMed Google Scholar, 16Beck A.W. Goodney P.P. Nolan B.W. Likosky D.S. Eldrup-Jorgensen J. Cronenwett J.L. Predicting 1-year mortality after elective abdominal aortic aneurysm repair.J Vasc Surg. 2009; 49 (discussion 843-4): 838-843Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar Pulmonary function is a significant factor for complications as well as short-term and long-term survival.17Svensson L.G. Hess K.R. Coselli J.S. Safi H.J. Crawford E.S. A prospective study of respiratory failure after high-risk surgery on the thoracoabdominal aorta.J Vasc Surg. 1991; 14: 271-282Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar The importance of age-related factors is highlighted by the stark difference in mortality risk of 0.7% (1 of 142 patients; no elective 30-day deaths) in our patients aged 60 years, even though there were more acute presentations in the younger patients (45% vs 31%). Surprisingly, previous coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) patients did not have increased mortality risk in our experience (6.4% with CABG or PTCA and 8.9% without, P = .3283). However, it is clear that cardiac function declines with age (Fig 3,A) and decreased cardiac reserve is associated with increased mortality risk. Cardiac function, as we have previously shown, is a risk factor for paraplegia, which is a significant factor in our multivariate model for mortality (Fig 3, B).18Acher C.W. Wynn M.M. Hoch J.R. Kranner P.W. Cardiac function is a risk factor for paralysis in thoracoabdominal aortic replacement.J Vasc Surg. 1998; 27 (discussion 829-30): 821-828Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar Renal function also declines significantly with age (Fig 4) and is independently significant for death, as is age (Table II).Fig 4Renal function, a significant factor for mortality, declines with age, but age and reduced renal function remain significant independent factors for mortality.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Table IIMultivariate model for operative mortalityVariableMortalityOdds ratioPAge, Y/N, yrs74.98/66.351.0896 per yr<.0001Acute, Y/N, %17.81/3.135.285<.0001Paraplegia, Y/N, %25.71/6.223.397.0194Pre-op creatinine, Y/N, mg/dL1.80/1.311.3906 per mg/dL.0289 Open table in a new tab The increase in mortality risk with age is apparent when comparing elective and acute mortality risk by decade (Table III). Three factors define the highest risk group of patients: those aged >80, with creatinine >2 mg/dL, who present acutely. Our 30-day mortality rate was 75% in this group. Of these, 40% died of cardiac causes, 26% of pulmonary causes, and 20% of multiorgan system failure, but half of these began with pneumonia. It is also clear from this analysis that age-related comorbidities help define that elusive quality of vitality that may improve survival probability.Table IIIMortality by decade in 771 patients surgically treated for thoracoabdominal and thoracic aortic aneurysmsaAcute patients were defined as having rupture, contained rupture, acute dissection, mycotic aortitis, trauma, plaque, or intramural hemorrhage.Age by decadeNo.Mortality, % electiveAcute 80705.1341.94a Acute patients were defined as having rupture, contained rupture, acute dissection, mycotic aortitis, trauma, plaque, or intramural hemorrhage. Open table in a new tab The decline in paraplegia risk during the last 25 years has been significant, with O/E ratios declining from an average of 1 to 0.25 or less in most clinical reports in the last decade (Table I). For instance, the paraplegia rate at Baylor in Houston has declined from 16% (O/E 1.0) during the Crawford era to 3.8% (O/E 0.22) in the Coselli era.19Svensson L.G. Crawford E.S. Hess K.R. Coselli J.S. Safi H.J. Experience with 1509 patients undergoing thoracoabdominal aortic operations.Journal of Vascular Surgery. 1993; 17 (discussion 368-70): 357-368Abstract Full Text Full Text PDF PubMed Scopus (1030) Google Scholar, 20Coselli J.S. Lemaire S.A. Koksoy C. Schmittling Z.C. Curling P.E. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial.J Vasc Surg. 2002; 35: 631-639Abstract Full Text Full Text PDF PubMed Scopus (472) Google Scholar Similar declines are reported by other authors when comparing results from reports in the early 1990s with the last decade21Griepp R.B. Ergin M.A. Galla J.D. Lansman S. Khan N. Quintana C. et al.Looking for the artery of Adamkiewicz: a quest to minimize paraplegia after operations for aneurysms of the descending thoracic and thoracoabdominal aorta.J Thorac Cardiovasc Surg. 1996; 112 (discussion 1213-5): 1202-1213Abstract Full Text Full Text PDF PubMed Scopus (231) Google Scholar, 22Safi H.J. Hess K.R. Randel M. Iliopoulos D.C. Baldwin J.C. Mootha R.K. et al.Cerebrospinal fluid drainage and distal aortic perfusion: reducing neurologic complications in repair of thoracoabdominal aortic aneurysm types I and II.J Vasc Surg. 1996; 23 (discussion 229): 223-228Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar, 23Svensson L.G. Intraoperative identification of spinal cord blood supply during repairs of descending aorta and thoracoabdominal aorta.J Thorac Cardiovasc Surg. 1996; 112 (discussion 1460-1): 1455-1460Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar (Table I). This decline is the result of the clinical introduction of the experimentally validated interventions of spinal fluid drainage (SFD) and hypothermia, along with increasing arterial perfusion pressure and improving neurochemical protection using steroids, naloxone, and barbiturates.4Acher C. Wynn M. Naloxone and spinal fluid drainage as adjuncts in the surgical treatment of thoracoabdominal aneurysms.Surgery. 1990; 108: 755-762PubMed Google Scholar, 24Acher C.W. Wynn M. A modern theory of paraplegia in the treatment of aneurysms of the thoracoabdominal aorta: an analysis of technique specific observed/expected ratios for paralysis.J Vasc Surg. 2009; 49 (discussion 1124): 1117-1124Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Adequate perfusion pressure and the transition from normothermic to hypothermic perfusion when using assisted circulation have also been identified by several authors as important strategies in preventing paraplegia.2Jacobs M.J. Elenbaas T.W. Schurink G.W. Mess W.H. Mochtar B. Assessment of spinal cord integrity during thoracoabdominal aortic aneurysm repair.Ann Thorac Surg. 2002; 74 (discussion S92-8): S1864-S1866Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar, 25Svensson L.G. Hess K.R. D'Agostino R.S. Entrup M.H. Hreib K. Kimmel W.A. et al.Reduction of neurologic injury after high-risk thoracoabdominal aortic operation.Ann Thorac Surg. 1998; 66: 132-138Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar, 26Etz C.D. Halstead J.C. Spielvogel D. Shahani R. Lazala R. Homann T.M. et al.Thoracic and thoracoabdominal aneurysm repair: is reimplantation of spinal cord arteries a waste of time?.Ann Thorac Surg. 2006; 82: 1670-1677Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar Since the introduction of these strategies in the mid-1980s, the paralysis rate at UW declined from 25% (O/E 1.04) to 3.3% (O/E 0.18) and has been quite stable since 1990 when we first reported our results.4Acher C. Wynn M. Naloxone and spinal fluid drainage as adjuncts in the surgical treatment of thoracoabdominal aneurysms.Surgery. 1990; 108: 755-762PubMed Google Scholar, 27Acher C.W. Wynn M.M. Mell M.W. Tefera G. Hoch J.R. A quantitative assessment of the impact of intercostal artery reimplantation on paralysis risk in thoracoabdominal aortic aneurysm repair.Ann Surg. 2008; 248: 529-540PubMed Google Scholar In our experience, the most important factors for paraplegia in multivariate modeling are acuity, extent of aortic replacement, cardiac index, and the spinal cord protection protocol of SFD, hypothermia, steroids, and naloxone (SFDN; Table IV). A lower cardiac index after unclamping the aorta, indicating reduced cardiac reserve, was associated with a greater risk of paralysis (Fig 5).Table IVParaplegia factorsaHigher cardiac index and use of our spinal cord protection protocol were protective from paraplegia, whereas extent of replacement (Crawford type C2), dissection, and acute presentation were associated with increased paralysis risk.VariableORPCrawford type 2 (Y)12.45<.0001SFDN (Y)0.251.0034Cardiac index (per unit increase)0.630.0272Acute (Y)2.736.0175Dissection (Y)4.567.0012OR, Odds ratio; SFD, spinal fluid drainage; SFDN, and naloxone.a Higher cardiac index and use of our spinal cord protection protocol were protective from paraplegia, whereas extent of replacement (Crawford type C2), dissection, and acute presentation were associated with increased paralysis risk. Open table in a new tab OR, Odds ratio; SFD, spinal fluid drainage; SFDN, and naloxone. Although age is a significant univariate factor, it is trumped by cardiac index in multivariate modeling, unlike mortality risk where the opposite is true. The implication of this is that a stronger pump is important for collateral perfusion and prevails regardless of age. Mean arterial pressure, age, renal function, and aortic occlusion time were not as important. Core temperature was not a significant factor, but we aggressively cool patients to 80 years and complications such as renal failure and paraplegia compromise long-term survival and functional recovery, leading to less than optimal long-term results and quality of life, with only 20% of patients surviving at 10 years.32Eide T.M. Romundstad P. Klepstad P. Myhre H.O. Health-related quality of life in long term-survivors of thoracoabdominal aortic aneurysm repair.J Vasc Nurs. 2005; 23 (quiz 5): 88-94Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 33Schepens M.A. Kelder J.C. Morshuis W.J. Heijmen R.H. van Dongen E.P. ter Beek H.T. Long-term follow-up after thoracoabdominal aortic aneurysm repair.Ann Thorac Surg. 2007; 83 (discussion S90-2): S851-S855Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar The increasing awareness of the importance of quality of life—and not just survival—should be a significant consideration when counseling patients and making recommendations for treatment.
Referência(s)