Redo lateral thoracotomy for reoperative descending and thoracoabdominal aortic repair: a consecutive series of 60 patients.

BACKGROUND

Reoperative descending thoracic aorta (DTA) or thoracoabdominal aortic aneurysm (TAAA) surgery is a challenge because of increased risk of lung injury and diffuse bleeding.

METHODS

Sixty patients (34 male, mean age 54.4 years) underwent redo thoracotomy for DTA (22 patients) or extended thoracoabdominal incision for reoperative TAAA (38 patients) from March 1988 to June 2007, after 1.7 +/- 0.9 previous cardioaortic procedures. Forty-one patients were hypertensive (68%), 18 were smokers (30%), 9 had Marfan syndrome (15%), 9 had coronary artery disease (15%), 5 had chronic obstructive pulmonary disease (8%), and 3 had diabetes mellitus (5%). In all, 45% (27 patients) had previous dissection, 30% (18) had atherosclerotic aneurysms, 15% had coarctation surgery (9), and 6 patients had other etiologies. Mean follow-up, 100% complete, was 6.5 years.

RESULTS

Hospital mortality for reoperative DTA/TAAA was 13.3% (8 patients). Although 6.3 +/- 2.9 (0 to 14) segmental artery pairs were sacrificed at reoperation-and 6.2 +/- 2.3 (1 to 12) initially-for a total of 10.6 +/- 3.9 (2 to 15) segmental artery pairs sacrificed, only 1 patient had paraplegia (1.6%). Four patients had a 2-day procedure, with 12 to 24 hours of intensive care unit recovery after lysis of extensive adhesions: all survived. Respiratory complications occurred in 13 patients (21.6%), and permanent dialysis was required in 2 (3.3%), but there were no strokes. Adverse outcome-1-year mortality, stroke, permanent dialysis, or paraplegia-occurred in 13 patients (21.6%). Adverse outcome was marginally associated (p < 0.2) with increased age, atherosclerotic aneurysms (33% versus 17% other), TAA incision (30% versus 9%), and greater aneurysm extent, and was significantly associated with perfusion technique (p = 0.02). Adverse outcome occurred in 3 of 4 patients who had clamp-and-sew technique, 6 of 21 using partial cardiopulmonary bypass (28.6%), and 3 of 17 with partial left heart bypass (17.7%), but only 1 of 18 with hypothermic circulatory arrest (5.6%).

CONCLUSIONS

Reoperative DTA/TAAA repair was significantly safer with hypothermic circulatory arrest rather than partial cardiopulmonary bypass, partial left heart bypass, or clamp-and-sew strategy. A 2-day procedure may be advisable for patients with extensive adhesions.