Japanese perspective in surgery for thoracoabdominal aortic aneurysms.

OBJECTIVE

Operative mortality and morbidity after thoracoabdominal aortic surgery remain high. We report our strategy and outcomes, especially those of spinal cord protection.

METHODS

Outcomes of 178 patients (age: 26-88 years) who underwent thoracoabdominal aortic replacement were retrospectively analyzed. 65 had aortic dissection, 14 had infected aneurysms, and 22 presented with rupture. Operations were non-elective in 24 and redo through re-thoracotomy in 21. Extent of replacement was Crawford-I in 39, II in 26, III in 78, and IV in 35. Staged repair was recently preferred, which resulted in decrease in extent II repair and increase in redo since 2009. Operations were performed under distal aortic perfusion and multi-segmental sequential repair to maximize collateral blood flow, and deep hypothermic circulatory arrest was preserved for those requiring open aortic anastomosis (n = 20). A total of 166 separate grafts were used for intercostal reconstruction in 88 patients, which was guided by preoperative feeding artery localization. Their patency was studied by postoperative MD-CT in 74 patients for 145 grafts.

RESULTS

There were 3.9% hospital mortality and 5.1% spinal cord injury. Preoperative feeding artery localization resulted in reduced number of reconstruction and improved patency, and grafts connecting to the feeding artery were patent in 92%. Results of redo operations were not different (no mortality and spinal cord injury) from the de novo operations.

CONCLUSIONS

Our concept of spinal cord protection, which was based on selective intercostal reconstruction while maximizing spinal cord collateral blood flow, seems justified.