Narrative review: open surgery for thoracoabdominal aortic aneurysm—is it still a horrible surgery?

Abstract

With the introduction of endovascular stent graft technology, options are available for treating patients with thoracoabdominal aortic aneurysms (TAAAs). However, open repair, despite its invasiveness, is still considered the gold standard for managing TAAA. Because this operation necessitates a large incision and is associated with life-threatening operative risk and serious life-altering postoperative complications such as paraplegia and renal failure, open repair may be described with ominous adjectives such as terrifying or horrible. Even large-volume centers of excellence have a relatively high incidence of mortality and morbidity, which contributes to the serious reputation of this surgery. However, over the years, steps have been taken to help mitigate risks in open repair, including the use of left heart bypass, cerebrospinal fluid drainage, cold renal perfusion, and reimplantation of intercostal and lumbar arteries, and early outcomes have generally improved. Late durability of open repair is well established. Endovascular repair of less complex descending thoracic aortic aneurysms is widely considered a good alternative to open surgical repair;notably, these are aneurysms that do not involve the visceral arteries. Experimental endovascular approaches for repairing TAAAs are emerging, but a substantial subset of patients may remain better suited for open repair because of anatomic and other limitations as well as some significant risks that are associated with endovascular repair. Endovascular repair of aneurysms involving visceral branches may be challenging even with fenestrated or branched endovascular graft technology. For many patient groups undergoing TAAA repair, protective adjuncts and overall durability have imparted significant benefits and support the continued need for open repair, making it far from a horrible surgery.