joseph s. coselli, m.d. outcomes of 3309 thoracoabdominal aortic aneurysm repairs 95 th annual...
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Joseph S. Coselli, M.D.?
Outcomes of 3309 Thoracoabdominal Aortic Aneurysm Repairs
95th Annual Meeting, American Association of Thoracic Surgery (AATS)Plenary Scientific Session: Abstract 1
Seattle, Washington • Monday, April 27, 2015
Matt D. Price, MSAlan Stolz, Med
Susan Y. Green, MPHCourtney N. Arredondo, MSPH
Todd K. Rosengart, MD
Scott A. LeMaire, MDOurania Preventza, MD
Kim I de la Cruz, MDDenton A. Cooley, MD
Disclosure
GlaxoSmithKline PI Clinical Trial
Vascutek, a Terumo company
PI Clinical TrialRoyaltiesConsultantEducational Grant
Medtronic, Inc PI Clinical TrialConsultant
WL Gore & Associates
PI Clinical TrialConsultant
ThoracoabdominalAortic Aneurysm
• E. Stanley Crawford refined and standardized repair Improved technique Categorized by extent of
repair Greatest aortic surgeon of era
E. Stanley Crawford1922-1992
ThoracoabdominalAortic Aneurysm
• E. Stanley Crawford refined and standardized repair Improved technique Categorized by extent of
repair Greatest aortic surgeon of era Our practice built on his
legacy
E. Stanley Crawford1922-1992
3309 TAAA Repairs October 1986 to December 2014
Study Enrollment• Clinical research protocol approved by
Baylor College of Medicine in 2006• Prospective from 2006• Retrospective before 2006• Single-practice series
Patient Characteristics (n = 3309) n (%) Median age, y [IQR]; range 12 y to 92 67 [59-73]
Age ≤ 50 y 439 (13.3)
Age > 79 y 193 (5.8)
Thoracoabdominal Aortic Aneurysm Repair
Patient Characteristics (n = 3309) n (%) Median age, y [IQR]; range 12 y to 92 67 [59-73]
Age ≤ 50 y 439 (13.3)
Age > 79 y 193 (5.8)
Aortic dissection involving distal aorta 1185 (35.1)
Acute or subacute dissection 165 (5.0)
Chronic dissection 1020 (30.8)
Thoracoabdominal Aortic Aneurysm Repair
Patient Characteristics (n = 3309) n (%) Median age, y [IQR]; range 12 y to 92 67 [59-73]
Age ≤ 50 y 439 (13.3)
Age > 79 y 193 (5.8)
Aortic dissection involving distal aorta 1185 (35.1)
Acute or subacute dissection 165 (5.0)
Chronic dissection 1020 (30.8)
Connective tissue disorder 330 (10.0)
Marfan syndrome 288 (8.7)
Thoracoabdominal Aortic Aneurysm Repair
Extent Age y [IQR]
Chronic Dissection
n (%)
ConnectiveTissue Disorder
n (%)
I(n=914)
67 [57-73] 352 (38.5) 67 (7.3)
II(n=1066)
66 [56-72] 469 (44.0) 177 (16.6)
III(n=660)
69 [61-74] 124 (18.8) 56 (8.5)
IV(n=669)
70 [64-75] 75 (11.2) 30 (4.5)
Total 67 [59-73] 1020 (30.8) 330 (10.0)
3309 TAAA RepairsPreoperative Characteristics by Extent of Repair
P=0.0001 P<0.001 P<0.001
III
IIIIV
0
5
10
15
20
25
30
35
40
45
50
16.4 20.3
4.94.3
30.5 28.5
14.4
7.6
DeBakey I DeBakey III
Aortic Dissection by Type (%)
Patient Characteristics (n = 3309) n (%) Hypertension 2805 (84.8)
Hyperlipidemia 967 (29.2)
Diabetes 261 (7.9)
Coronary artery disease 1232 (37.2)
Previous coronary artery bypass graft 496 (15.0)
Prior myocardial infarction 652 (19.7)
Thoracoabdominal Aortic Aneurysm Repair
P<0.001 P<0.001 P<0.001
ExtentCoronary Artery
Disease, n (%)Previous CABG
n (%)Previous MI
n (%)
I(n=914)
259 (28.3) 98 (10.7) 131 (14.3)
II(n=1066)
351 (32.9) 136 (12.8) 181 (17.0)
III(n=660)
291 (44.1) 121 (18.3) 162 (24.6)
IV(n=669)
331 (49.5) 141 (21.1) 178 (26.6)
Total 1232 (37.2) 496 (15.0) 652 (19.7)
3309 TAAA RepairsCoronary Artery Disease by Extent of Repair
P=0.004 P=0.1
Extent
Chronic renal insufficiency
n (%)Chronic renal failure
n (%)
I(n=914)
15 (1.6) 11 (1.2)
II(n=1066)
28 (2.6) 17 (1.6)
III(n=660)
30 (4.6) 18 (2.7)
IV(n=669)
26 (3.9) 14 (2.1)
Total 99 (3.0) 60 (1.8)
3309 TAAA RepairsPreoperative Characteristics by Extent of Repair
P<0.001 P<0.001 P<0.001
ExtentPulmonary disease
n (%)COPDn (%)
Past /Current Tobaccon (%)
I(n=914)
314 (34.4) 288 (31.5) 669 (73.2)
II(n=1066)
363 (34.1) 334 (31.3) 835 (78.3)
III(n=660)
322 (48.8) 303 (45.91) 546 (82.7)
IV(n=669)
299 (44.7) 289 (43.2) 566 (84.6)
Total 1298 (39.2) 1214 (36.7) 2616 (79.1)
3309 TAAA RepairsPreoperative Characteristics by Extent of Repair
P=0.5 P=0.5 P=0.3
ExtentAsymptomatic
no. (%)Symptomatic
no. (%)Acute symptoms
no. (%)
I(n=914)
311 (34.0) 603 (66.0) 169 (18.5)
II(n=1066)
400 (37.5) 666 (62.5) 161 (15.1)
III(n=660)
239 (36.2) 421 (63.8) 109 (16.5)
IV(n=669)
242 (36.2) 427 (63.8) 110 (16.4)
Total 1192 (36.0) 2117 (64.0) 549 (16.6)
3309 TAAA RepairsPreoperative Symptoms by Extent of Repair
P<0.001 P<0.001
ExtentRupture
n (%)
Peripheral Vascular Disease
n (%)I
(n=914)48 (5.3) 148 (16.2)
II(n=1066)
32 (3.0) 252 (23.6)
III(n=660)
43 (6.5) 191 (28.9)
IV(n=669)
47 (7.0) 264 (39.5)
Total 170 (5.1) 855 (25.8)
3309 TAAA RepairsRupture and PVD by Extent of Repair
P<0.001 P<0.001
ExtentPrior aortic repair
n (%)
Failure of Prior Aortic Repair
n (%)
I(n=914)
145 (15.9) 9 (1.0)
II(n=1066)
198 (18.6) 23 (2.2)
III(n=660)
276 (41.8) 47 (7.1)
IV(n=669)
244 (36.5) 57 (8.5)
Total 863 (26.1) 136 (4.1)
3309 TAAA RepairsPrior Aortic Repair by Extent of Repair
Intraoperative Strategies
All extents• Moderate heparinization• Permissive mild hypothermia• Aggressive reattachment of
segmental arteries• Cold renal perfusion whenever
renal ostia can be accessed• Expeditious repair
Extent I and II repairs• Cerebrospinal fluid drainage• Left heart bypass• Selective celiac/SMA perfusion
P=0.03 P=0.4 P=0.02
ExtentElective
n (%)Urgentn (%)
Emergentn (%)
I(n=914)
700 (76.6) 131 (14.3) 83 (9.1)
II(n=1066)
866 (81.2) 127 (11.9) 73 (6.8)
III(n=660)
504 (76.4) 86 (13.0) 70 (10.6)
IV(n=669)
516 (77.1) 84 (12.6) 69 (10.3)
Total 2586 (78.2) 428 (12.9) 295 (8.9)
3309 TAAA RepairsUrgency of Repair by Extent of Repair
Operative Details (n = 3309) n (%) Redo thoracotomy 563 (17.0)
Extraction of endograft 48 (1.5)
Extraction of TEVAR 29 (0.7)
Reverse elephant trunk 80 (2.4)
Completion of elephant trunk 133 (4.0)
Clamping proximal to the left subclavian artery (LSCA)
517 (15.6)
Thoracoabdominal Aortic Aneurysm Repair
P<.001 P<.001 P<.001
ExtentAortic Clamp Time
min, med [IQR]Intercostal Total Time min, med [IQR]
Intercostal Unprotected Time
min, med [IQR]I
(n=914)40.5 [32-52] 40.0 [31-50] 26.0 [20-32]
II(n=1066)
63.0 [53-75] 52.0 [41-63.5] 35.0 [27-42]
III(n=660)
43.0 [34-53] 35.0 [27-44] 33.5 [26-42]
IV(n=669)
41.0 [31-50.8] 41.0 [31-50.8] 31.0 [24-40]
Total 48.0 [36-62] 40.0 [30-52] 31.0 [24-39]
3309 TAAA RepairsAortic Clamp and Ischemic Times by Extent of Repair
P<.001
Extent
Intercostal/Lumbar Artery Reattachment
n (%)
I(n=914)
498 (54.5)
II(n=1066)
941 (88.3)
III(n=660)
221 (33.5)
IV(n=669)
15 (2.2)
Total 1675 (50.6)
3309 TAAA RepairsOperative Details by Extent of Repair
P<0.001 P<0.001 P<0.001 P<0.001
ExtentVisceral/Renal Endarterectomy
n (%)
Visceral/Renal Stentn (%)
Visceral/Renal Endarterectomy
or Stentn (%)
Visceral/Renal Endarterectomy or
Stent or Bypassn (%)
I(n=914)
51 (5.6) 15 (1.6) 58 (6.3) 88 (9.6)
II(n=1066)
275 (25.8) 86 (8.1) 303 (28.4) 510 (47.8)
III(n=660)
250 (37.9) 73 (11.1) 270 (40.9) 357 (54.1)
IV(n=669)
281 (42.0) 90 (13.5) 90 (13.5) 405 (60.5)
Total 857 (25.9) 264 (8.0) 940 (28.4) 1360 (41.1)
3309 TAAA RepairsManagement of Visceral Arteries by Extent of Repair
P<.001 P<.001
ExtentLeft Heart Bypass
n (%)
Selective Celiac/Superior Mesenteric
n (%)
I(n=914)
557 (60.9) 60 (6.6)
II(n=1066)
874 (82.0) 675 (63.3)
III(n=660)
43 (6.5) 36 (5.5)
IV(n=669)
6 (0.9) 8 (1.2)
Total 1480 (44.7) 779 (23.5)
3309 TAAA RepairsPerfusion by Extent of Repair
P<.001
ExtentCold Renal Perfusion
n (%)
I(n=914)
158 (17.3)
II(n=1066)
701 (65.8)
III(n=660)
511 (77.4)
IV(n=669)
564 (84.3)
Total 1934 (58.4)
3309 TAAA RepairsOperative Details by Extent of Repair
• The most inclusive category of early death: In-hospital death regardless of the
length of hospital stay In-hospital death includes any
death after transfer to another hospital or long term acute care facility
30-day death, including those rare deaths after discharge to home
Operative Mortality
• A composite endpoint• Comprised of:
Operative mortality
Permanent stroke Permanent paraplegia Permanent paraparesis Permanent renal failure
Adverse Event
Permanent = present at time of hospital discharge or early death
30-day or in-hospital death, including death after transfer
• Discharge of early survivors with a complication that negatively impacts quality of life and longevity
• Discharge with unresolved: Paraplegia Paraparesis Stroke Renal failure necessitating
dialysis
Life-Altering Complication
P<.001 P=.002 P=.01
ExtentAdverse Event
n (%)Operative Death
n (%)30-Dayn (%)
I(n=914)
98 (10.7) 54 (5.9) 34 (3.7)
II(n=1066)
203 (19.0) 101 (9.5) 68 (6.4)
III(n=660)
110 (16.7) 58 (8.8) 34 (5.2)
IV(n=669)
67 (10.0) 36 (5.4) 23 (3.4)
Total 478 (14.4) 249 (7.5) 159 (4.8)
3309 TAAA RepairsEarly Outcomes by Extent of Repair
3309 TAAA RepairsSelect Rates of Operative Mortality
Subgroups of interest nEarly Death
n (%) PPatients ≤ 50 y 439 14 (3.2%) <.001
Patients > 79 y 193 37 (19.2%) <.001
Connective tissue disorder 330 10 (3.0%) .001
Chronic aortic dissection 1020 58 (5.7%) .007
Rupture 170 37 (21.8%) <.001
Prior aortic repair 858 70 (8.2%) .4
Elective repair 2586 161 (6.2%) <.001
Urgent or emergent repair 723 88 (12.2%) <.001
P<.001 P=.004 P=.04
ExtentAll Stroke
n (%)Stroke, Permanent
n (%)Stroke, Temporary
n (%)
I(n=914)
33 (3.6) 22 (2.4) 11 (1.2)
II(n=1066)
46 (4.3) 36 (3.4) 10 (0.9)
III(n=660)
9 (1.4) 7 (1.1) 2 (0.3)
IV(n=669)
10 (1.5) 9 (1.3) 1 (0.1)
Total 98 (3.0) 74 (2.2) 24 (0.7)
3309 TAAA RepairsEarly Outcomes by Extent of Repair
P<.001 P<.001 P=.1
Extent
Spinal Cord Deficits
n (%)
Permanent Paraplegia
n (%)
Permanent Paraparesis
n (%)
I(n=914)
71 (7.8) 12 (1.3) 19 (2.1)
II(n=1066)
147 (13.9) 50 (4.7) 35 (3.3)
III(n=660)
71 (10.8) 29 (4.4) 17 (2.6)
IV(n=669)
27 (4.0) 6 (0.9) 10 (1.5)
Total 317 (9.6) 97 (2.9) 81 (2.4)
3309 TAAA RepairsEarly Outcomes by Extent of Repair
Periods Without Permanent ParaplegiaOctober 1986 to December 2014
Gap of ≥ 50 Date 1 Date 2Sequential cases without
paraplegia1 Oct 1991 May 1992 69
2 May 1992 Nov 1992 51
3 July 1993 Apr 1995 261
4 Apr 1995 Oct 1995 92
5 Sep 1996 May 1997 117
6 Apr 1998 Feb 1999 113
7 Feb 1999 May 1999 51
8 May 2000 Aug 2000 60
9 Dec 2000 Apr 2001 53
10 Feb 2002 July 2002 84
11 July 2002 Feb 2003 102
12 Nov 2003 Apr 2004 65
13 June 2004
Dec 2004 62
14 Jan 2007 Dec 2007 90
15 Dec 2010 May 2011 50
16 Mar 2014 Dec 2014 67
P<.001 P=.001 P=.6
Extent
Acute Renal Dysfunction
n (%)
Permanent Renal Failuren (%)
Temporary Renal Failuren (%)
I(n=914)
73 (8.0) 29 (3.2) 16 (1.8)
II(n=1066)
170 (15.9) 78 (7.3) 24 (2.3)
III(n=660)
81 (12.3) 43 (6.5) 9 (1.4)
IV(n=669)
82 (12.3) 39 (5.8) 12 (1.8)
Total 406 (12.3) 189 (5.7) 61 (1.8)
3309 TAAA RepairsEarly Outcomes by Extent of Repair
P=.03 P=.08 P=.001
Extent
Survival with Renal Failure
n (%)
Survival with Permanent Stroke
n (%)
Survival with Permanent Paraplegia
n (%)
I(n=914)
12 (1.3) 9 (1.0) 7 (0.8)
II(n=1066)
36 (3.4) 18 (1.7) 25 (2.3)
III(n=660)
17 (2.6) 4 (0.6) 17 (2.6)
IV(n=669)
17 (2.5) 4 (0.6) 3 (0.4)
Total 82 (2.5) 35 (1.1) 52 (1.6)
3309 TAAA RepairsSurvivors: Life-Altering Complications by Extent of Repair
Operative Mortality RRR p valueAge (by increasing year) 1.05 <.001Clamp time (by increasing min) 1.01 <.001Rupture 2.38 <.001Renal insufficiency 1.98 .02Symptomatic aneurysm 1.62 .004Endarterectomy, stent, or bypass 1.46 <.001
Thoracoabdominal Aortic Aneurysms: Predictors: Multivariate Analysis
Extent IV repair 0.50 0.001
n= 249 cases of operative mortality
Paraplegia in Extent II RRR p valueCoronary artery disease 1.92 .03Chronic aortic symptoms 3.00 .001Past or current tobacco use 2.75 .1 (NS)
Thoracoabdominal Aortic Aneurysms Independent Predictors: Multivariate Analysis
n= 50 cases of permanent paraplegia in extent II TAAA repair
Paraplegia in Extent II RRR p valueCoronary artery disease 1.92 .03Chronic aortic symptoms 3.00 .001Past or current tobacco use 2.75 .1 (NS)
Thoracoabdominal Aortic Aneurysms Independent Predictors: Multivariate Analysis
Genetically triggered disorder 0.23 .05
n= 50 cases of permanent paraplegia in extent II TAAA repair
Paraplegia in Extent II RRR p valueCoronary artery disease 1.92 .03Chronic aortic symptoms 3.00 .001Past or current tobacco use 2.75 .1 (NS)
Thoracoabdominal Aortic Aneurysms Independent Predictors: Multivariate Analysis
Genetically triggered disorder 0.23 .05Reduces risk by 77%
n= 50 cases of permanent paraplegia in extent II TAAA repair
Paraplegia in Extent II RRR p valueCoronary artery disease 1.92 .03Chronic aortic symptoms 3.00 .001Past or current tobacco use 2.75 .1 (NS)
Thoracoabdominal Aortic Aneurysms Independent Predictors: Multivariate Analysis
Genetically triggered disorder 0.23 .05Reduces risk by 77%Reattachment of intercostal or lumbar arteries 0.46 .03
n= 50 cases of permanent paraplegia in extent II TAAA repair
Paraplegia in Extent II RRR p valueCoronary artery disease 1.92 .03Chronic aortic symptoms 3.00 .001Past or current tobacco use 2.75 .1 (NS)
Thoracoabdominal Aortic Aneurysms Independent Predictors: Multivariate Analysis
Genetically triggered disorder 0.23 .05Reduces risk by 77%Reattachment of intercostal or lumbar arteries 0.46 .03
Reduces risk by 54%
n= 50 cases of permanent paraplegia in extent II TAAA repair
Long-term Survival
Number at Risk
3309 1684 724 194Follow up (Years)
Su
rviv
al (
%) 63.6 ± 0.9
36.8 ± 1.0
18.3 ± 0.9
All
Long-term Survival by Extent
I/II P < 0.001I/III P < 0.001I/IV P < 0.001II/III P = 0.003II/IV P = 0.085III/IV P = 0.270S
urv
ival
(%
)
Follow up (Years)
Extent IExtent IIExtent IIIExtent IV
Number at Risk
914 525 274 781066 539 237 58
660 314 112 28
669 306 101 30
Long-term Survival by Rupture
Number at Risk
3139 1634 704 187170 50 22 7
Follow up (Years)
Su
rviv
al (
%)
No RuptureRupture
64.9 ± 0.9
37.6 ± 1.0
18.7 ± 1.039.3 ± 4.1
20.4 ± 3.69.6 ± 3.1
Long-term Survival by Genetic Disorder
Number at Risk
523 308 164 602786 1376 560 134
Su
rviv
al (
%)
Follow up (Years)
Genetic DisorderNo Genetic Disorder
60.3 ± 1.0
82.3 ± 4.1
32.1 ± 1.0
14.0 ± 0.9
65.8 ± 2.6
47.4 ± 3.3
Long-term Survival by Aortic Dissection
Number at Risk
1196 647 324 972113 1037 400 97
Su
rviv
al (
%)
Follow up (Years)
DissectionNo Dissection
73.7 ± 1.4
58.3 ± 1.1
52.1 ± 1.7
31.4 ± 2.0
29.2 ± 1.1
12.2 ± 0.9
Follow up (Years)
Long-term Survival in Those Discharged With a Life-Altering Complication
P = 0.004
Number at Risk
2831 1600 694 186229 84 30 8
Su
rviv
al (
%)
No Life AlteringLife Altering
70.5 ± 0.9
48.5 ± 3.6
41.2 ± 1.1
20.5 ± 1.0
22.0 ± 3.3
9.9 ± 2.8
Early Survivors by Genetic Disorder
Number at Risk
2555 1360 545 133505 301 156 56
Follow up (Years)
No Genetic DisorderGenetic Disorder
98.1 ± 0.3
97.1 ± 0.8
Fre
edo
m f
rom
Rep
air
Fai
lure
(%
) 96.0 ± 0.6 95.5 ± 0.7
92.6 ± 1.6 90.2 ± 2.1
• Contemporary TAAA repair yields good-to-excellent outcomes in experienced centers
• Results are generally better in younger patients Patients with Marfan syndrome Survivors of DeBakey I dissection Extent I and II
• Long-term survival reasonable Patients are usually > 65 years and generally achieve
near life expectancy• Repairs are reliable
Few late events or secondary reinterventions
Conclusions