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Early and Late Outcomes After Descending Thoracic and Thoracoabdominal Aneurysm Repair: Does Chronic Dissection Impart a Greater Risk?

Mark F. Conrad, Thomas K. Chung, Matthew R. Cambria, Vikram Paruchuri, Richard P. Cambria.
Massachusetts General Hospital, Boston, Mass.

OBJECTIVES: Chronic aortic dissection (CD) has traditionally been considered a predictor of morbidity and mortality after descending thoracic/thoracoabdominal aneurysm repair (TAR). While recent reports have rejected this assertion for the peri-operative period, few contemporary studies document late outcomes after TAR for CD, which is the goal of this study.

METHODS: From 8/1987-12/2005, 480 patients underwent TAR; 73 (15%) CD and 407 (85%) degenerative aneurysms (DA). Operative management consisted of a clamp-and-sew technique with adjuncts in 53 (78%) CD and 355 (93%) DA patients (p<0.001). Epidural cooling was used to prevent spinal cord injury (SCI) in 51 (70%) CD and 214 (53%) DA patients (p=0.007). Study endpoints included peri-operative SCI/mortality, freedom from aneurysm-related complication (ARC) and long-term survival.

RESULTS: CD patients were younger (mean age 64.5 CD vs. 72.5 DA, p<0.001) and had a family history of aneurysmal disease (23.3% CD vs. 6.4% DA, p<0.001). 47 (65%) CD patients were symptomatic at presentation (vs. 132 (34.6%) DA, p<0.001) and 43 (59%) CD patients had elective TAR (vs. 322 (79%) DA, p=0.001). 11 (15%) CD patients had Marfan’s syndrome (vs. 0 DA, p<0.001) and 17 (23%) CD patients had a prior arch or ascending aortic repair (vs. 16 (4%) DA, p<0.001). CD patients were more likely to have Crawford type I&II thoracoabdominal aneurysms (44 (60%) vs. 120 (29%) DA, p<0.001)) while only 2 (3%) CD patients had type IV aneurysms (vs. 99 (24%) DA). There was no difference in peri-operative mortality between the two groups (11% CD vs. 8.6% DA, p=0.52) nor was there a difference in any degree of SCI (16.4% CD vs. 11.1% DA, p=0.19). SCI was immediate in 6 (8%) CD and 19 (4.7%) DA patients (p=0.21) while flaccid paralysis occurred in 3 (4%) CD and 14 (3%) DA patients (p=0.92). At five years, 70% of CD patients were free from ARC vs. 74% of DA (p=0.36). The actuarial survival was 60%, 47% and 39% at 5, 10 and 12 years for CD vs. 56%, 28% and 21% for DA (p=0.049).

CONCLUSIONS: Despite a higher risk pre-operative profile, CD does not appear to increase peri-operative SCI or mortality after TAR when compared to DA. Long-term freedom from ARC is similar for both groups and patients who undergo TAR for CD can expect a better long-term survival than those with DA likely due to younger age at presentation.
 
AUTHOR DISCLOSURES:  M.F. Conrad, None; T.K. Chung, None; M.R. Cambria, None; V. Paruchuri, None; R.P. Cambria, None.