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Extracorporeal Circulation During Open Repair of DTA and TAA Aneurysms Improves Late Survival

Key findings

  • Use of extracorporeal circulation (EC) during open repair of thoracic and thoracoabdominal aortic aneurysms had a favorable impact on perioperative outcomes, late outcomes and hospital charges
  • 30-day mortality was 9.7% with EC versus 12.2% without
  • The incidence of acute renal failure was 14% with EC versus 24% without
  • The addition of EC was associated with an adjusted 31% improvement in long-term survival
  • EC should be a more widely applied adjunct in open DTA or TAA aneurysm repair

There is no standardized approach to surgical repair of descending thoracic aorta (DTA) or thoracoabdominal aorta (TAA) aneurysms. Studies conflict about whether the benefits of extracorporeal circulation (EC) outweigh its increased technical complexity compared with “clamp and sew” approaches. Furthermore, most existing studies are limited to single institutions or single-surgeon series.

Massachusetts General Hospital vascular surgeons evaluated the effects of EC using nationwide data on U.S. Medicare recipients. In the Journal of Vascular Surgery, they report that EC was associated with improved late survival and a significant reduction in operative mortality, morbidity and procedural costs.

The researchers identified 4230 patients who had open DTA or TAA aneurysm repair between 2004 and 2007 and did not have a simultaneous concomitant cardiac procedure or a procedure employing cardioplegia or deep hypothermic circulatory arrest. For over half of patients (57%), EC was used as an adjunct during the repair. The co-primary outcomes of the study were 30-day mortality, long-term survival and predictors of late mortality. The research team first calculated that the use of EC was associated with significant benefits in terms of:

  • 30-day mortality rate: 9.7% with EC vs 12.2% without (P = .01)
  • Overall complication rate: 49% with EC vs 58% without (P < .0001)
  • Rates of pulmonary complications (21% vs 27%), bleeding (13% vs 19%) and acute renal failure (14% vs 24%) (P < .0001 for all comparisons)
  • Length of hospital stay (9 days vs 11 days; P < .0001)
  • Discharge to home (67% vs 56%; P < .0001)
  • Average hospital charges ($151,000 vs $180,000; P < .0001)

On regression analysis, EC was independently associated with a statistically significant 20% reduction in operative mortality, 33% reduced risk of any complication, 32% reduced risk of pulmonary complications and 48% reduced risk of acute renal failure.

EC was also independently associated with a significant 31% improvement in long-term survival (P < .0001). A Kaplan-Meier analysis showed significantly higher survival in the EC group at 1 year after surgery (81% with EC vs 73% without) and at 5 years (67% vs 52%) (P < .01).

The researchers note that because they used Medicare data, this study reflects the impact of EC across multiple institutions, patient populations, practice patterns and surgeons. They conclude that EC should be more widely used during open repair of DTA and TAA aneurysms.

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