Late Complications Unlikely After Open Type IV Thoracoabdominal Aortic Aneurysm Repair

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Thanks to evolution in techniques, open type IV thoracoabdominal aortic aneurysm (TAAA) repair typically has excellent outcomes, with a low rate of perioperative complication. However, the impact of late complications has been poorly defined.

Based on nearly 27 years of data, a team of Massachusetts General Hospital vascular surgeons including Mark Conrad, MD, director of Clinical Research in the Division of Vascular and Endovascular Surgery, report in the Journal of Vascular Surgery that late aortic and graft-related complications are uncommon after open type IV TAAA repair, and aortic-related mortality is low.

The team analyzed data on 226 patients who underwent type IV TAAA repair between January 11, 1989, and October 27, 2015, at Mass General. Type IV aneurysm extent was defined as total abdominal aneurysm encompassing the entirety of the visceral segment and requiring graft replacement cephalad to the celiac axis.

Most reconstructions (90%) were performed with a proximal beveled anastomosis encompassing the celiac, superior mesenteric and right renal arteries. The other procedures were performed with proximal end-to-end anastomosis to the lower descending thoracic aorta with inclusion button for the visceral segment and left renal bypass.

Incidence of Complications

Of the participants, 33 patients (15%) had an aortic or graft-related event an average of 2.2 years postoperatively. Three of those patients had multiple complications: two had both an aortic and a graft-related event, and one had two aortic events and one graft-related event. Total complications were as follows:

• Aortic events: 19 patients (8%): elective aortic repair (n=15), emergent repair (n=2) and atheroembolization (n=2) occurring an average of 2.6 years after repair
• Graft-related events: 17 patients (8%): occlusion of a renal artery or renal reconstruction (n =10), anastomotic aneurysm repair (n=5), graft infection (n=1) and graft-caval fistula (n=1) occurring an average of 1.7 years after repair

The longest-term event was an anastomotic aneurysm repair that was required six years and six months after initial surgery.

Reintervention for a complication was required in 24 patients (11%). Four patients (2%) died as a direct result of a late aortic or graft-related event.

Predictors of Complications

The factors that predicted post-discharge complications were not surprising, the researchers say. On multivariable analysis, the independent predictors of an aortic event were initial rupture (hazard ratio, 5.6; 95% CI, 1.4–23.1; P = .02) and native aortic expansion during surveillance (HR, 3.9; 95% CI, 1.05–14.9; P = .04). No significant predictors of graft-related events were identified.

For prediction of any complication (aortic or graft-related), only rupture at presentation was significant (HR, 3.1; 95% CI, 1.1–9.1; P = .04).

Freedom from Complications

The research team calculated rates of freedom from:

• Any complication: 93% at 1 year, 66% at 5 years
• An aortic complication: 98% at 1 year, 78% at 5 years
• A graft-related complication: 95% at 1 year, 84% at 5 years
• Reintervention: 96% at 1 year, 86% at 5 years
• Aortic-related mortality: 97% at 1 year, 95% at 5 years

Conclusions

Currently, open and endovascular repair of type IV TAAA seem to provide similar freedom from aneurysm- or aortic-related mortality, the researchers conclude. They add that open repair seems to provide a benefit with fewer reinterventions, and the five-year freedom from aortic or graft events suggests the durability of type IV TAAA reconstruction.

Even so, periodic clinical and imaging surveillance is reasonable, the authors recommend. Their standard protocol includes physical examination and review within eight weeks after discharge. Computed tomography angiography is obtained at one year in all patients and scans are repeatedly annually for patients with abnormal remaining aortic segments or as clinically indicated.

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