Open thoracoabdominal aortic aneurysm repair in the modern era: results from a 20-year single-centre experience

Murana, Giacomo; Castrovinci, Sebastiano; Kloppenburg, Geoffrey T.L.; Yousif, Afram; Kelder, Hans; Schepens, Marc A.A.M.; Maat, Gijs E. De; Sonker, Uday; Morshuis, Wim J.; Heijmen, Robin H.

doi:10.1093/ejcts/ezv415

Cited by 89 publications

(68 citation statements)

References 21 publications

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“…5, 7, 8, 25 The rates of spinal cord ischemia demonstrated in this analysis are consistent with the literature, and were significantly lower in the group undergoing staged hybrid repair at 8% compared to 19% in the standard open repair cohort. The hybrid repair methodology effectively converts an extent II TAAA into an extent III/IV TAAA.…”

Section: Discussionsupporting

confidence: 88%

“…These less extensive aneurysm repairs are associated with much lower rates of spinal cord ischemia. 7, 26 Additionally, it has been previously demonstrated that staged open procedures, first thoracic aneurysm repair followed by distal abdominal repair, was associated with a decreased rate of spinal cord injury from 17% to 0%. 27 Our results demonstrate that this outcome can be replicated using TEVAR.…”

Section: Discussionmentioning

confidence: 99%

“…5, 7, 29 The rate of AKI after TEVAR varies with complexity of lesion and definition of kidney injury, but has been reported to be between 17-23%. 30, 31 It is therefore not surprising to see increased AKI in our staged hybrid group since these patients are undergoing a previous procedure causing renal insult in one fifth of all patients.…”

Section: Discussionmentioning

confidence: 99%

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Improved outcomes and value in staged hybrid extent II thoracoabdominal aortic aneurysm repair

Hawkins

Mehaffey

Narahari

et al. 2017

Journal of Vascular Surgery

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Objective Complex Crawford extent II thoracoabdominal aortic aneurysms (TAAA) can be treated in a hybrid manner with proximal thoracic endovascular aneurysm repair, followed by staged distal open thoracoabdominal repair. The purpose of this study was to evaluate the outcomes and healthcare associated value of this new method compared to traditional open repair over 10 years. Methods A prospectively collected database was used to identify all patients with extent II TAAA undergoing repair at a single institution between 2005 and 2015. Patient characteristics, post-operative outcomes, and incidence of major adverse events (MAE = renal failure, spinal cord ischemia, death) were compared. After adjusting for time since surgery, value was analyzed looking at quality (1/MAE) divided by cost (total health system cost). This is multiplied by a constant to set the value of open TAAA repair to 100. Results A total of 113 consecutive patients underwent extent II TAAA repairs, of which 25 (22.1%) had a staged hybrid approach with a median of 129 days between procedures. No baseline differences in demographic or comorbidity variables existed between groups (p>0.05). The hybrid group had shorter operative time (255 vs 306 minutes; p=0.01), shorter postoperative length of stay (LOS) (10.1 vs 13.3 days; p=0.02), as well as reduced blood loss (1300 vs 2600 mL; p=0.01) at the time of open operation. Despite higher rates of acute kidney injury in the hybrid group (76.0%vs 51.1%, p=0.03) there was no difference in renal failure (8.0% vs 4.5%, p=0.84) The incidence of MAE was lower in the staged hybrid group (20.0% vs 48.9%; p=0.01), without a difference in hospital mortality (4.0 vs 3.4%, p=0.89). Median total cost was higher in the hybrid group ($112,920 vs $72,037, p=0.003). Value was improved in the hybrid group by 56% using mean cost and 178% by median cost. Conclusions The 20% major adverse event rate associated with staged hybrid repair of extent II TAAA was significantly decreased compared to open repair, with a relative reduction of over 50%. Despite higher total hospital costs, staged hybrid repair had 56% to 178% higher healthcare related value compared to standard open repair. In an era of increasing focus on costs and quality, staged hybrid repair of extensive TAAAs is associated with fewer complications than open TAAA repair resulting in a good value investment from a resource utilization perspective.

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Section: Discussionsupporting

confidence: 88%

Section: Discussionmentioning

confidence: 99%

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Improved outcomes and value in staged hybrid extent II thoracoabdominal aortic aneurysm repair

Hawkins

Mehaffey

Narahari

et al. 2017

Journal of Vascular Surgery

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“…Clinically, surgical repair of thoracoabdominal aneurysm can lead to temporary or permanent spinal cord I/R injury, whose incidence varies between 3% and 20% [1]. A major pathological change in spinal cord I/R injury is BSCB disruption, which further leads to neurological deficit.…”

Section: Introductionmentioning

confidence: 99%

Remote Ischemia Preconditioning Attenuates Blood-Spinal Cord Barrier Breakdown in Rats Undergoing Spinal Cord Ischemia Reperfusion Injury: Associated with Activation and Upregulation of CB1 and CB2 Receptors

Niu¹,

Fang²,

Wang³

et al. 2017

Cell Physiol Biochem

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Background/Aims: Remote ischemic preconditioning (RIPC) has protective effects on spinal cord ischemia reperfusion (I/R) injury, but the potential mechanisms remain unclear. In our study, the effects and underlying mechanisms of RIPC on blood-spinal cord barrier (BSCB) breakdown following I/R injury were investigated. Methods: animals underwent intraperitoneal administration with cannabinoid-1 (CB1) receptor antagonist AM251, cannabinoid-2 (CB2) receptor antagonist AM630 or vehicle 15 minutes before three 3-minute occlusion-reperfusion cycles on the right femoral artery or a sham operation. 30 minutes after the preconditioning, aortic arch was exposed with or without 14-minute occlusion. Neurological function was assessed with Tarlov scoring system. The disruption of BSCB was assessed by measuring Evans Blue (EB) extravasation. The expression of tight junction protein occludin was determined by western blot analyses. The expression and localization of CB1 and CB2 receptors were assessed by western blot and immunofluorescence. Results: RIPC attenuated the motor dysfunction, BSCB disruption and downregulation of occludin after I/R injury, which were impaired by blocking CB1 and CB2 receptors. Moreover, RIPC upregulated the elevated perivascular expression of CB1 and CB2 receptors following I/R injury. Conclusions: These results indicated that RIPC, through activation and upregulation of CB1 and CB2 receptors, was involved in preserving the integrity of BSCB after spinal cord I/R injury.

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“…64). Nevertheless, paraplegia and paraparesis still exist postoperatively, leaving room for new protective innovations.…”

mentioning

confidence: 99%

Review of remote ischemic preconditioning: from laboratory studies to clinical trials

Anttila

Haapanen

Yannopoulos

et al. 2016

Scandinavian Cardiovascular Journal

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In remote ischemic preconditioning (RIPC) short periods of non-lethal ischemia followed by reperfusion of tissue or organ prepare remote tissue or organ to resist a subsequent more severe ischemia-reperfusion injury. The signaling mechanism of RIPC can be humoral communication, neuronal stimulation, systemic modification of circulating immune cells, and activation of hypoxia inducible genes. Despite promising evidence from experimental studies, the clinical effects of RIPC have been controversial. Heterogeneity of inclusion and exclusion criteria and confounding factors such as comedication, anesthesia, comorbidities, and other risk factors may have influenced the efficacy of RIPC. Although the cardioprotective pathways of RIPC are more widely studied, there is also evidence of benefits in CNS, kidney and liver protection. Future research should explore the potential of RIPC, not only in cardiac protection, but also in patients with threatening ischemia of the brain, organ transplantation of the heart, liver and kidney and extensive cardiovascular surgery. RIPC is generally well-tolerated, safe, effective, and easily feasible. It has a great prospect for ischemic protection of the heart and other organs.

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Open thoracoabdominal aortic aneurysm repair in the modern era: results from a 20-year single-centre experience

Abstract: In elective cases, open TAAA repair has to be considered an effective option associated with low necessity of reoperation at follow-up. The extent of aortic resection did not affect long-term mortality. Conversely, survival was mainly determined by patient age and preoperative condition.

Cited by 89 publications

References 21 publications

Improved outcomes and value in staged hybrid extent II thoracoabdominal aortic aneurysm repair

Improved outcomes and value in staged hybrid extent II thoracoabdominal aortic aneurysm repair

Remote Ischemia Preconditioning Attenuates Blood-Spinal Cord Barrier Breakdown in Rats Undergoing Spinal Cord Ischemia Reperfusion Injury: Associated with Activation and Upregulation of CB1 and CB2 Receptors

Review of remote ischemic preconditioning: from laboratory studies to clinical trials

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