Early Gastrointestinal Complications After Open Thoracoabdominal Aortic Aneurysm Repair

Identifying risk factors for postoperative ileus following open abdominal aortic aneurysm repair

BACKGROUND

Postoperative ileus (POI) is a common complication following major abdominal surgery. The majority of the data available regarding POI after abdominal surgery is from the gastrointestinal and urological literature. These data have been extrapolated to vascular surgery, especially with regard to enhanced recovery programs for open abdominal aortic aneurysm (AAA) surgery. However, vascular patients are a unique patient population and extrapolation of gastrointestinal and urological data may not necessarily be appropriate. Therefore, the purpose of this study was to delineate the prevalence and risk factors of POI in patients undergoing open AAA surgery.

METHODS

This was a retrospective, single-institution study of patients who underwent open AAA surgery from January 2016 to July 2023. Patients were excluded if they had undergone nonelective repairs or had expired within 72 hours of their index operation. The primary outcome was rates of POI, which was defined as the presence of two or more of the following after the third postoperative day: nausea and/or vomiting, inability to tolerate oral food intake, absence of flatus, abdominal distension, or radiological evidence of ileus.

RESULTS

A total of 123 patients met study criteria with an overall POI rate of 8.9% (n = 11). Patients who developed a POI had a significantly lower body mass index (24.3 kg/m2 vs 27.1 kg/m2; P = .003), were more likely to undergo a transperitoneal approach (81.8% vs 42.0%; P = .022), midline laparotomy (81.8% vs 37.5%; P = .008), longer total clamp times (151.6 minutes vs 97.7 minutes; P = .018), greater amounts of intraoperative crystalloid infusion (3495 mL vs 2628 mL; P = .029), and were more likely to return to the operating room (27.3% vs 3.6%; P = .016). Proximal clamp site was not associated with POI (P=.463). Patients with POI also had higher rates of postoperative vasopressor use (100% vs 61.1%; P = .014) and greater amounts of oral morphine equivalents in the first 3 postoperative days (488.0 ± 216.0 mg vs 203.8 ± 29.6 mg; P = .016). Patients who developed POI had longer lengths of stay (12.5 days vs 7.6 days; P < .001), a longer duration of nasogastric tube decompression (5.9 days vs 2.2 days; P < .001), and a longer period of time before diet tolerance (9.1 days vs 3.7 days; P < .001). Of those who developed a POI (n = 11), four (36.4%) required total parental nutrition during the admission.

CONCLUSIONS

POI is a morbid complication among patients undergoing elective open AAA surgery that prolongs hospital stay. Patients at risk for developing a POI are those with a lower body mass index, as well as those who had an operative repair via a transperitoneal approach, midline laparotomy, longer clamp times, larger amounts of intraoperative crystalloid infusion, a return to the operating room, postoperative vasopressor use, and higher amounts of oral morphine equivalents. These data highlight important perioperative opportunities to decrease the prevalence of POI.

Long-term results of fenestrated and branched endovascular aneurysm repair for complex abdominal and thoracoabdominal aortic aneurysms in young and fit patients

BACKGROUND

Endovascular repair of complex abdominal aortic aneurysms (CAAAa) and thoracoabdominal aortic aneurysms (TAAAs) with fenestrated and branched devices (F/BEVAR) represents the first-line treatment in old or unfit patients. Currently, the widespread diffusion of these techniques has led to a progressive increase of complex endovascular procedures also in younger and fitter patients, but the related results have been only minimally reported, without long-term data. We investigated the long-term results of F/BEVAR for CAAA and TAAA repair in young and fit patients.

METHODS

All consecutive patients, aged ≤70 years, who underwent F/BEVAR for CAAA and TAAA over the last 13 years at two tertiary institutions were included in the study. All subjects presented a low to intermediate risk according to the Society for Vascular Surgery clinical comorbidity grading system. The primary end points were technical and clinical success and late overall and aortic-related survival. Major complications and specific target vessel-related outcomes were investigated as secondary end points.

RESULTS

A total of 183 patients (155 males [84.7%]; mean age, 64.5 ± 5.7 years; range, 33-70 years) underwent F/BEVAR during the study period, for a total of 167 degenerative (91.3%) and 16 postdissection (8.7%) aneurysms, including 44 (24%) juxtarenal, 33 (18%) pararenal, and 106 (58%) TAAAs. Technical and clinical success were achieved in 176 patients (96.2%) and 171 patients (93.4%), respectively. Four patients (2.2%) died perioperatively, of which two (1.1%) operated in emergency. Postoperatively, five patients (2.7%) presented permanent grade 3 spinal cord injury and three (1.6%) renal failure needing permanent dialysis. The mean follow-up was 65.7 ± 39.6 months (range, 1-158 months). The estimated overall and aortic-related survival at 12, 60, and 120 months was 94.0%, 85.1%, 72.2%, and 97.8%, 97.8%, 96.2%, respectively, and reintervention and branch instability-free survival at the same time points were 84.4%, 71.8%, 71.8%, and 93.2%, 86.3%, 72.2%, respectively. An aneurysm growth of >5 mm was detected in six patients (3.3%), and a sac shrinkage of >5 mm was achieved in 118 cases (64.5%). The Cox regression analysis demonstrated the need for unplanned procedure as the only risk factor for overall mortality (odds ratio, 3.331; 95% confidence interval, 1.397-7.940; P < .01].

CONCLUSIONS

F/BEVAR in young and fit patients led to low perioperative mortality and major morbidity rates and a favorable overall survival rate in the long-term, making this technique particularly appealing in such a subgroup of patients. The availability of long-term data derived from the results of young patients, may additionally provide helpful information to redefine the indications for treatment and allow future targeted device and technique improvements.

Independent associations with early mortality after open repair of Crawford extent IV thoracoabdominal aortic aneurysms

OBJECTIVE

We aimed to identify outcomes and factors that independently associate with early mortality after open repair of Crawford extent IV thoracoabdominal aortic aneurysms, defined as aneurysms confined to the segment below the diaphragm.

METHODS

This retrospective analysis included 721 extent IV thoracoabdominal aortic aneurysm repairs performed in our institution from 1986 to 2021. Indications for repair were aneurysm without dissection in 627 cases (87.0%) and aortic dissection in 94 cases (13.0%). Overall, 466 patients (64.6%) were symptomatic preoperatively; 124 (17.2%) procedures were performed in patients with acute presentation, including 58 (8.0%) ruptured aneurysms.

RESULTS

Operative death occurred after 49 (6.8%) repairs. Persistent renal failure necessitating dialysis occurred after 43 (6.0%) repairs. Binary logistic regression modeling revealed that previous extent II thoracoabdominal aortic aneurysm repair, chronic kidney disease, previous myocardial infarction, urgent or emergency repair, and longer crossclamp times during surgery were independently associated with operative mortality. Among early survivors (n = 672), competing risk analysis revealed that cumulative incidence of mortality and reintervention rates at 10 years were 74.8% (95% confidence interval, 71.4%-78.5%) and 3.3% (95% confidence interval, 2.2%-5.1%), respectively.

CONCLUSIONS

Although patient comorbidities contributed to operative mortality, factors associated with the repair, such as urgent or emergency status, the duration of aortic crossclamping, and certain types of complex reoperation, also played prominent roles. Patients who survive the operation can expect a durable repair that usually is free from late reintervention. Expanding our collective knowledge regarding patients who undergo open repair of extent IV thoracoabdominal aortic aneurysms will enable clinicians to establish best practices and improve patient outcomes.

Early outcomes from the pivotal trial of a four-branch off-the shelf solution to treat complex abdominal and type IV thoracoabdominal aortic aneurysms

BACKGROUND

This study reports the 30-day outcomes of the primary arm of the GORE EXCLUDER Thoracoabdominal Branch Endoprosthesis (TAMBE) pivotal trial for complex abdominal aortic aneurysm repair.

METHODS

This multicenter, nonrandomized, prospective study of the TAMBE device included patients enrolled in the primary study arm of extent IV thoracoabdominal aortic aneurysms and pararenal aneurysms. Technical success and major adverse events were analyzed per the Society for Vascular Surgery guidelines.

RESULTS

The 102 patients of the primary arm who underwent endovascular repair using the TAMBE device were a mean age of 73 ± 6.4 years (range, 58-82 years) and 84 (84.2%) were male. The mean body mass index was 28.3 ± 5.0 kg/m2. Fifty-nine patients (57.8%) were treated for extent IV and 43 (42.2%) pararenal aneurysms; the mean maximum diameter of the aneurysms was 59.4 ± 7.8 mm. A prophylactic cerebral spinal fluid drain was used in 10 patients (9.8%). Technical success was achieved in 99% of patients, with the single failure owing to unsuccessful cannulation of the left renal artery. Mean procedure time was 315 ± 103 minutes (range, 163-944 minutes), estimated blood loss was 300 ± 296 mL (range, 10-2000 mL), and contrast administration was 153.6 ± 73.5 mL (range, 16-420 mL). The intensive care unit length of stay was 58.7 ± 52.7 hours (range, 1-288 mL). In 28 patients (27.5%), a total of 32 additional endovascular components were deployed to manage procedural complications including aortic and target vessel dissections and injuries not related to access. Bridging stent grafts were deployed to incorporate 407 target vessels (mean 1.6/per vessel; range, 1-4). Postoperative transfusion was required in 14 patients (13.7%). Major adverse events occurred in seven patients (6.9%) through 30 days. Events included respiratory failure (n = 2), disabling stroke (n = 1), new-onset renal failure requiring dialysis (n = 2), and paraplegia (n = 2). At 30 days, there was one patient with intraoperative rupture; no severe bowel ischemia or lesion-related/all-cause mortality were reported. The Core lab-reported patency was 100% in the aortic component, superior mesenteric artery, and celiac artery, and 95.9% in the left renal and 99.0% in the right renal branch components through 30 days of follow-up. Reinterventions through 30 days were performed in 9 of 96 patients (9.4%) and were all minor.

CONCLUSIONS

Early TAMBE device outcomes demonstrate a high technical success rate, no 30-day lesion-related mortality, and a low rate of safety events within 30 days of the index procedure.

Two cases of pararenal artery aortic aneurysm treatment after pancreaticoduodenectomy and abdominal aortic aneurysm stent grafting

BACKGROUND

Acute pancreatitis caused by surgical procedures may occur less frequently in surgeries for aortic aneurysm involving the abdominal branch. However, in such cases, the associated mortality rate increases significantly. There have been few reports on abdominal aortic aneurysm surgery after pancreatoduodenectomy; as such the incidence of postoperative pancreatitis remains unclear.

CASE PRESENTATION

Two cases of pararenal artery aortic aneurysm after pancreaticoduodenectomy and endovascular aneurysm repair (EVAR) for an abdominal aortic aneurysm are reported. In the first case, a 74-year-old man was diagnosed with abdominal aortic aneurysm and duodenal cancer 6 years earlier and underwent pancreaticoduodenectomy after EVAR. Subsequently, the abdominal aorta expanded to 58 mm at the level of the renal artery proximal to the EVAR site. Graft replacement was performed through a left thoraco-retroperitoneal incision. However, the patient died from acute pancreatitis, believed to be caused by intraoperative manipulation. Given this initial experience, in the second case, a 77-year-old man had undergone a pancreaticoduodenectomy for a gastrointestinal stromal tumor 17 years earlier and EVAR for an abdominal aortic aneurysm 10 years earlier. The abdominal aorta had expanded to 50 mm immediately below the right renal artery on the proximal side of the EVAR. Subsequently, hematuria was noted, and he was diagnosed with right ureteral cancer. Autologous transplantation of the left kidney and EVAR was performed avoiding manipulation of the area around the pancreas and achieved good results. Combined right renal and ureteral resections were performed 20 days after EVAR.

CONCLUSIONS

While performing aortic surgery after pancreaticoduodenectomy, surgeons should avoid manipulating tissues around the pancreas.

Risk Factors and Early Outcomes for Gastrointestinal Complications in Patients Undergoing Open Surgery for Type A Aortic Dissection

BACKGROUND

Gastrointestinal complications need to be paid more attention, especially in critically ill patients. The purpose of this study was to identify the risk factors and short-term outcomes of gastrointestinal complications after open surgery for type A aortic dissection.

METHODS

A retrospective single-institutional study including patients who underwent open surgery for type A aortic dissection during 2012-2020 was conducted. Univariate analysis and logistic regression analysis were used to identify risk factors associated with gastrointestinal complications. The related clinical outcomes were compared between the patients with and without gastrointestinal complications.

RESULTS

Among the 2746 patients, 150 developed gastrointestinal complications. The development of gastrointestinal complications contributed to the higher rate of mortality (P = .008), longer stay in the intensive care unit (P < .001), and longer hospital stay (P < .001). Logistic regression analysis showed that age (odds ratio [OR] 1.020; 95% confidence interval [CI] 1.005-1.057; P = .011), American Society of Anesthesiologists classification greater than grade III (OR 1.724; 95%CI 1.179-2.521, P = .005), pre-induction mean arterial pressure (OR 0.978; 95%CI 0.965-0.990, P = .001), aortic cross-clamp time (OR 1.012; 95%CI 1.005-1.019, P = .001), cardiopulmonary bypass time (OR 1.007; 95%CI 1.002-1.011, P = .002), and intraoperative transfusion of red blood cells (OR 1.214; 95%CI 1.122-1.314, P = .001) were independent risk factors for gastrointestinal complications.

CONCLUSIONS

The incidence of gastrointestinal complications after open surgery for type A aortic dissection was 5.5%, resulting in increased mortality and prolonged hospital stay. It is necessary to take suitable strategies to reduce the incidence of gastrointestinal complications.

The application of modular multifunctional left heart bypass circuit system integrated with ultrafiltration in thoracoabdominal aortic aneurysm repair

Open thoracoabdominal aortic aneurysm (TAAA) repair is a complex and challenging operation with a high incidence of serious complications, and high perioperative mortality and morbidity. Left heart bypass (LHB) is a circulatory support system used to perfuse the distal aorta during TAAA operation, and the advantages of LHB include guaranteeing distal perfusion, reducing the use of heparin, and diminishing the risk of bleeding and postoperative neurological deficits. In China, the circuit for TAAA repair is deficient, and far from the perfusion requirements. We designed a modular multifunctional LHB circuit for TAAA repair. The modular circuit consisted of cannulation pipelines, functional consumables connection pipelines, and accessory pipelines. The accessory pipelines make up lines for selective visceral perfusion and kidney perfusion, suckers and rapid infusion. The circuit can be assembled according to surgical requirements. The ultrafilter and heat exchanger are integrated into the circuit to fulfill the basic demands of LHB. The LHB circuit also has pipelines for selective visceral perfusion to the celiac artery and superior mesenteric artery and renal perfusion pipelines. Meanwhile, the reserved pipelines facilitate the quick switch from LHB to conventional cardiopulmonary bypass (CPB). The reserved pipelines reduce the time of reassembling the CPB circuit. Moreover, the rapid infusion was integrated into the LHB circuit, which can rapid infusion when massive hemorrhage during the open procedures such as exposure and reconstruction of the aorta. The ultrafiltration can diminish the consequent hemodilution of hemorrhage and rapid infusion. A hemoperfusion cartridge also can be added to reduce the systemic inflammatory during operation. The circuit can meet the needs of LHB and quickly switch to conventional CPB. No oxygenator was required during LHB, which reduce the use of heparin and reduce the risk of bleeding. The heat exchanger contributes to temperature regulation; ultrafiltration, arterial filter, and rapid-infusion facilitated the blood volume management and are useful to maintain hemodynamic stability. This circuit made the assembly of the LHB circuit more easily, and more efficient, which may contribute to the TAAA repair operation performed in lower volume centers easily. 26 patients who received TAAA repair under the modular multifunctional LHB from January 2018-March 2022 were analyzed, and we achieved acceptable clinical outcomes. The in-hospital mortality and 30-day postoperative mortality were 15.4%, and the postoperative incidences of paraparesis (4%), stroke (4%), and AKI need hemodialysis (12%) were not particularly high, based on the limited patients sample size in short research period duration.