Joseph S. Coselli, M.D. Outcomes of 3309 Thoracoabdominal Aortic Aneurysm Repairs 95 th Annual Meeting, American Association of Thoracic Surgery (AATS)

Joseph S. Coselli, M.D.?

Outcomes of 3309 Thoracoabdominal Aortic Aneurysm Repairs

95th Annual Meeting, American Association of Thoracic Surgery (AATS)Plenary Scientific Session: Abstract 1

Seattle, Washington • Monday, April 27, 2015

Matt D. Price, MSAlan Stolz, Med

Susan Y. Green, MPHCourtney N. Arredondo, MSPH

Todd K. Rosengart, MD

Scott A. LeMaire, MDOurania Preventza, MD

Kim I de la Cruz, MDDenton A. Cooley, MD

Disclosure

GlaxoSmithKline PI Clinical Trial

Vascutek, a Terumo company

PI Clinical TrialRoyaltiesConsultantEducational Grant

Medtronic, Inc PI Clinical TrialConsultant

WL Gore & Associates

PI Clinical TrialConsultant

ThoracoabdominalAortic Aneurysm

• E. Stanley Crawford refined and standardized repair Improved technique Categorized by extent of

repair Greatest aortic surgeon of era

E. Stanley Crawford1922-1992

ThoracoabdominalAortic Aneurysm

• E. Stanley Crawford refined and standardized repair Improved technique Categorized by extent of

repair Greatest aortic surgeon of era Our practice built on his

legacy

E. Stanley Crawford1922-1992

3309 TAAA Repairs October 1986 to December 2014

Study Enrollment• Clinical research protocol approved by

Baylor College of Medicine in 2006• Prospective from 2006• Retrospective before 2006• Single-practice series

914 6601066

669

Patient Characteristics (n = 3309) n (%) Median age, y [IQR]; range 12 y to 92 67 [59-73]

Age ≤ 50 y 439 (13.3)

Age > 79 y 193 (5.8)

Thoracoabdominal Aortic Aneurysm Repair


Age ≤ 50 y 439 (13.3)

Age > 79 y 193 (5.8)

Aortic dissection involving distal aorta 1185 (35.1)

Acute or subacute dissection 165 (5.0)

Chronic dissection 1020 (30.8)



Age ≤ 50 y 439 (13.3)

Age > 79 y 193 (5.8)

Aortic dissection involving distal aorta 1185 (35.1)

Acute or subacute dissection 165 (5.0)

Chronic dissection 1020 (30.8)

Connective tissue disorder 330 (10.0)

Marfan syndrome 288 (8.7)


Extent Age y [IQR]

Chronic Dissection

n (%)

ConnectiveTissue Disorder

n (%)

I(n=914)

67 [57-73] 352 (38.5) 67 (7.3)

II(n=1066)

66 [56-72] 469 (44.0) 177 (16.6)

III(n=660)

69 [61-74] 124 (18.8) 56 (8.5)

IV(n=669)

70 [64-75] 75 (11.2) 30 (4.5)

Total 67 [59-73] 1020 (30.8) 330 (10.0)

3309 TAAA RepairsPreoperative Characteristics by Extent of Repair

P=0.0001 P<0.001 P<0.001

III

IIIIV

0

5

10

15

20

25

30

35

40

45

50

16.4 20.3

4.94.3

30.5 28.5

14.4

7.6

DeBakey I DeBakey III

Aortic Dissection by Type (%)

Patient Characteristics (n = 3309) n (%) Hypertension 2805 (84.8)

Hyperlipidemia 967 (29.2)

Diabetes 261 (7.9)

Coronary artery disease 1232 (37.2)

Previous coronary artery bypass graft 496 (15.0)

Prior myocardial infarction 652 (19.7)


P<0.001 P<0.001 P<0.001

ExtentCoronary Artery

Disease, n (%)Previous CABG

n (%)Previous MI

n (%)

I(n=914)

259 (28.3) 98 (10.7) 131 (14.3)

II(n=1066)

351 (32.9) 136 (12.8) 181 (17.0)

III(n=660)

291 (44.1) 121 (18.3) 162 (24.6)

IV(n=669)

331 (49.5) 141 (21.1) 178 (26.6)

Total 1232 (37.2) 496 (15.0) 652 (19.7)

3309 TAAA RepairsCoronary Artery Disease by Extent of Repair

P=0.004 P=0.1

Extent

Chronic renal insufficiency

n (%)Chronic renal failure

n (%)

I(n=914)

15 (1.6) 11 (1.2)

II(n=1066)

28 (2.6) 17 (1.6)

III(n=660)

30 (4.6) 18 (2.7)

IV(n=669)

26 (3.9) 14 (2.1)

Total 99 (3.0) 60 (1.8)


P<0.001 P<0.001 P<0.001

ExtentPulmonary disease

n (%)COPDn (%)

Past /Current Tobaccon (%)

I(n=914)

314 (34.4) 288 (31.5) 669 (73.2)

II(n=1066)

363 (34.1) 334 (31.3) 835 (78.3)

III(n=660)

322 (48.8) 303 (45.91) 546 (82.7)

IV(n=669)

299 (44.7) 289 (43.2) 566 (84.6)

Total 1298 (39.2) 1214 (36.7) 2616 (79.1)


P=0.5 P=0.5 P=0.3

ExtentAsymptomatic

no. (%)Symptomatic

no. (%)Acute symptoms

no. (%)

I(n=914)

311 (34.0) 603 (66.0) 169 (18.5)

II(n=1066)

400 (37.5) 666 (62.5) 161 (15.1)

III(n=660)

239 (36.2) 421 (63.8) 109 (16.5)

IV(n=669)

242 (36.2) 427 (63.8) 110 (16.4)

Total 1192 (36.0) 2117 (64.0) 549 (16.6)

3309 TAAA RepairsPreoperative Symptoms by Extent of Repair

P<0.001 P<0.001

ExtentRupture

n (%)

Peripheral Vascular Disease

n (%)I

(n=914)48 (5.3) 148 (16.2)

II(n=1066)

32 (3.0) 252 (23.6)

III(n=660)

43 (6.5) 191 (28.9)

IV(n=669)

47 (7.0) 264 (39.5)

Total 170 (5.1) 855 (25.8)

3309 TAAA RepairsRupture and PVD by Extent of Repair

P<0.001 P<0.001

ExtentPrior aortic repair

n (%)

Failure of Prior Aortic Repair

n (%)

I(n=914)

145 (15.9) 9 (1.0)

II(n=1066)

198 (18.6) 23 (2.2)

III(n=660)

276 (41.8) 47 (7.1)

IV(n=669)

244 (36.5) 57 (8.5)

Total 863 (26.1) 136 (4.1)

3309 TAAA RepairsPrior Aortic Repair by Extent of Repair

Intraoperative Strategies

All extents• Moderate heparinization• Permissive mild hypothermia• Aggressive reattachment of

segmental arteries• Cold renal perfusion whenever

renal ostia can be accessed• Expeditious repair

Extent I and II repairs• Cerebrospinal fluid drainage• Left heart bypass• Selective celiac/SMA perfusion

P=0.03 P=0.4 P=0.02

ExtentElective

n (%)Urgentn (%)

Emergentn (%)

I(n=914)

700 (76.6) 131 (14.3) 83 (9.1)

II(n=1066)

866 (81.2) 127 (11.9) 73 (6.8)

III(n=660)

504 (76.4) 86 (13.0) 70 (10.6)

IV(n=669)

516 (77.1) 84 (12.6) 69 (10.3)

Total 2586 (78.2) 428 (12.9) 295 (8.9)

3309 TAAA RepairsUrgency of Repair by Extent of Repair

Operative Details (n = 3309) n (%) Redo thoracotomy 563 (17.0)

Extraction of endograft 48 (1.5)

Extraction of TEVAR 29 (0.7)

Reverse elephant trunk 80 (2.4)

Completion of elephant trunk 133 (4.0)

Clamping proximal to the left subclavian artery (LSCA)

517 (15.6)


P<.001 P<.001 P<.001

ExtentAortic Clamp Time

min, med [IQR]Intercostal Total Time min, med [IQR]

Intercostal Unprotected Time

min, med [IQR]I

(n=914)40.5 [32-52] 40.0 [31-50] 26.0 [20-32]

II(n=1066)

63.0 [53-75] 52.0 [41-63.5] 35.0 [27-42]

III(n=660)

43.0 [34-53] 35.0 [27-44] 33.5 [26-42]

IV(n=669)

41.0 [31-50.8] 41.0 [31-50.8] 31.0 [24-40]

Total 48.0 [36-62] 40.0 [30-52] 31.0 [24-39]

3309 TAAA RepairsAortic Clamp and Ischemic Times by Extent of Repair

P<.001

Extent

Intercostal/Lumbar Artery Reattachment

n (%)

I(n=914)

498 (54.5)

II(n=1066)

941 (88.3)

III(n=660)

221 (33.5)

IV(n=669)

15 (2.2)

Total 1675 (50.6)

3309 TAAA RepairsOperative Details by Extent of Repair

P<0.001 P<0.001 P<0.001 P<0.001

ExtentVisceral/Renal Endarterectomy

n (%)

Visceral/Renal Stentn (%)

Visceral/Renal Endarterectomy

or Stentn (%)

Visceral/Renal Endarterectomy or

Stent or Bypassn (%)

I(n=914)

51 (5.6) 15 (1.6) 58 (6.3) 88 (9.6)

II(n=1066)

275 (25.8) 86 (8.1) 303 (28.4) 510 (47.8)

III(n=660)

250 (37.9) 73 (11.1) 270 (40.9) 357 (54.1)

IV(n=669)

281 (42.0) 90 (13.5) 90 (13.5) 405 (60.5)

Total 857 (25.9) 264 (8.0) 940 (28.4) 1360 (41.1)

3309 TAAA RepairsManagement of Visceral Arteries by Extent of Repair

P<.001 P<.001

ExtentLeft Heart Bypass

n (%)

Selective Celiac/Superior Mesenteric

n (%)

I(n=914)

557 (60.9) 60 (6.6)

II(n=1066)

874 (82.0) 675 (63.3)

III(n=660)

43 (6.5) 36 (5.5)

IV(n=669)

6 (0.9) 8 (1.2)

Total 1480 (44.7) 779 (23.5)

3309 TAAA RepairsPerfusion by Extent of Repair

P<.001

ExtentCold Renal Perfusion

n (%)

I(n=914)

158 (17.3)

II(n=1066)

701 (65.8)

III(n=660)

511 (77.4)

IV(n=669)

564 (84.3)

Total 1934 (58.4)

3309 TAAA RepairsOperative Details by Extent of Repair

• The most inclusive category of early death: In-hospital death regardless of the

length of hospital stay In-hospital death includes any

death after transfer to another hospital or long term acute care facility

30-day death, including those rare deaths after discharge to home

Operative Mortality

• A composite endpoint• Comprised of:

Operative mortality

Permanent stroke Permanent paraplegia Permanent paraparesis Permanent renal failure

Adverse Event

Permanent = present at time of hospital discharge or early death

30-day or in-hospital death, including death after transfer

• Discharge of early survivors with a complication that negatively impacts quality of life and longevity

• Discharge with unresolved: Paraplegia Paraparesis Stroke Renal failure necessitating

dialysis

Life-Altering Complication

P<.001 P=.002 P=.01

ExtentAdverse Event

n (%)Operative Death

n (%)30-Dayn (%)

I(n=914)

98 (10.7) 54 (5.9) 34 (3.7)

II(n=1066)

203 (19.0) 101 (9.5) 68 (6.4)

III(n=660)

110 (16.7) 58 (8.8) 34 (5.2)

IV(n=669)

67 (10.0) 36 (5.4) 23 (3.4)

Total 478 (14.4) 249 (7.5) 159 (4.8)

3309 TAAA RepairsEarly Outcomes by Extent of Repair

3309 TAAA RepairsSelect Rates of Operative Mortality

Subgroups of interest nEarly Death

n (%) PPatients ≤ 50 y 439 14 (3.2%) <.001

Patients > 79 y 193 37 (19.2%) <.001

Connective tissue disorder 330 10 (3.0%) .001

Chronic aortic dissection 1020 58 (5.7%) .007

Rupture 170 37 (21.8%) <.001

Prior aortic repair 858 70 (8.2%) .4

Elective repair 2586 161 (6.2%) <.001

Urgent or emergent repair 723 88 (12.2%) <.001

P<.001 P=.004 P=.04

ExtentAll Stroke

n (%)Stroke, Permanent

n (%)Stroke, Temporary

n (%)

I(n=914)

33 (3.6) 22 (2.4) 11 (1.2)

II(n=1066)

46 (4.3) 36 (3.4) 10 (0.9)

III(n=660)

9 (1.4) 7 (1.1) 2 (0.3)

IV(n=669)

10 (1.5) 9 (1.3) 1 (0.1)

Total 98 (3.0) 74 (2.2) 24 (0.7)


P<.001 P<.001 P=.1

Extent

Spinal Cord Deficits

n (%)

Permanent Paraplegia

n (%)

Permanent Paraparesis

n (%)

I(n=914)

71 (7.8) 12 (1.3) 19 (2.1)

II(n=1066)

147 (13.9) 50 (4.7) 35 (3.3)

III(n=660)

71 (10.8) 29 (4.4) 17 (2.6)

IV(n=669)

27 (4.0) 6 (0.9) 10 (1.5)

Total 317 (9.6) 97 (2.9) 81 (2.4)


Periods Without Permanent ParaplegiaOctober 1986 to December 2014

Gap of ≥ 50 Date 1 Date 2Sequential cases without

paraplegia1 Oct 1991 May 1992 69

2 May 1992 Nov 1992 51

3 July 1993 Apr 1995 261

4 Apr 1995 Oct 1995 92

5 Sep 1996 May 1997 117

6 Apr 1998 Feb 1999 113

7 Feb 1999 May 1999 51

8 May 2000 Aug 2000 60

9 Dec 2000 Apr 2001 53

10 Feb 2002 July 2002 84

11 July 2002 Feb 2003 102

12 Nov 2003 Apr 2004 65

13 June 2004

Dec 2004 62

14 Jan 2007 Dec 2007 90

15 Dec 2010 May 2011 50

16 Mar 2014 Dec 2014 67

P<.001 P=.001 P=.6

Extent

Acute Renal Dysfunction

n (%)

Permanent Renal Failuren (%)

Temporary Renal Failuren (%)

I(n=914)

73 (8.0) 29 (3.2) 16 (1.8)

II(n=1066)

170 (15.9) 78 (7.3) 24 (2.3)

III(n=660)

81 (12.3) 43 (6.5) 9 (1.4)

IV(n=669)

82 (12.3) 39 (5.8) 12 (1.8)

Total 406 (12.3) 189 (5.7) 61 (1.8)


P=.03 P=.08 P=.001

Extent

Survival with Renal Failure

n (%)

Survival with Permanent Stroke

n (%)

Survival with Permanent Paraplegia

n (%)

I(n=914)

12 (1.3) 9 (1.0) 7 (0.8)

II(n=1066)

36 (3.4) 18 (1.7) 25 (2.3)

III(n=660)

17 (2.6) 4 (0.6) 17 (2.6)

IV(n=669)

17 (2.5) 4 (0.6) 3 (0.4)

Total 82 (2.5) 35 (1.1) 52 (1.6)

3309 TAAA RepairsSurvivors: Life-Altering Complications by Extent of Repair

Operative Mortality RRR p valueAge (by increasing year) 1.05 <.001Clamp time (by increasing min) 1.01 <.001Rupture 2.38 <.001Renal insufficiency 1.98 .02Symptomatic aneurysm 1.62 .004Endarterectomy, stent, or bypass 1.46 <.001

Thoracoabdominal Aortic Aneurysms: Predictors: Multivariate Analysis

Extent IV repair 0.50 0.001

n= 249 cases of operative mortality

Paraplegia in Extent II RRR p valueCoronary artery disease 1.92 .03Chronic aortic symptoms 3.00 .001Past or current tobacco use 2.75 .1 (NS)

Thoracoabdominal Aortic Aneurysms Independent Predictors: Multivariate Analysis

n= 50 cases of permanent paraplegia in extent II TAAA repair



Genetically triggered disorder 0.23 .05




Genetically triggered disorder 0.23 .05Reduces risk by 77%




Genetically triggered disorder 0.23 .05Reduces risk by 77%Reattachment of intercostal or lumbar arteries 0.46 .03




Genetically triggered disorder 0.23 .05Reduces risk by 77%Reattachment of intercostal or lumbar arteries 0.46 .03

Reduces risk by 54%


Long-term Survival

Number at Risk

3309 1684 724 194Follow up (Years)

Su

rviv

al (

%) 63.6 ± 0.9

36.8 ± 1.0

18.3 ± 0.9

All

Long-term Survival by Age Cohorts

All lines are P < 0.001(from each other)

Long-term Survival by Extent

I/II P < 0.001I/III P < 0.001I/IV P < 0.001II/III P = 0.003II/IV P = 0.085III/IV P = 0.270S

urv

ival

(%

)

Follow up (Years)

Extent IExtent IIExtent IIIExtent IV

Number at Risk

914 525 274 781066 539 237 58

660 314 112 28

669 306 101 30

Long-term Survival by Rupture

Number at Risk

3139 1634 704 187170 50 22 7

Follow up (Years)

Su

rviv

al (

%)

No RuptureRupture

64.9 ± 0.9

37.6 ± 1.0

18.7 ± 1.039.3 ± 4.1

20.4 ± 3.69.6 ± 3.1

Long-term Survival by Genetic Disorder

Number at Risk

523 308 164 602786 1376 560 134

Su

rviv

al (

%)

Follow up (Years)

Genetic DisorderNo Genetic Disorder

60.3 ± 1.0

82.3 ± 4.1

32.1 ± 1.0

14.0 ± 0.9

65.8 ± 2.6

47.4 ± 3.3

Long-term Survival by Aortic Dissection

Number at Risk

1196 647 324 972113 1037 400 97

Su

rviv

al (

%)

Follow up (Years)

DissectionNo Dissection

73.7 ± 1.4

58.3 ± 1.1

52.1 ± 1.7

31.4 ± 2.0

29.2 ± 1.1

12.2 ± 0.9

Follow up (Years)

Long-term Survival in Those Discharged With a Life-Altering Complication

P = 0.004

Number at Risk

2831 1600 694 186229 84 30 8

Su

rviv

al (

%)

No Life AlteringLife Altering

70.5 ± 0.9

48.5 ± 3.6

41.2 ± 1.1

20.5 ± 1.0

22.0 ± 3.3

9.9 ± 2.8

Early Survivors by Genetic Disorder

Number at Risk

2555 1360 545 133505 301 156 56

Follow up (Years)

No Genetic DisorderGenetic Disorder

98.1 ± 0.3

97.1 ± 0.8

Fre

edo

m f

rom

Rep

air

Fai

lure

(%

) 96.0 ± 0.6 95.5 ± 0.7

92.6 ± 1.6 90.2 ± 2.1

Freedom from Repair Failure

• Contemporary TAAA repair yields good-to-excellent outcomes in experienced centers

• Results are generally better in younger patients Patients with Marfan syndrome Survivors of DeBakey I dissection Extent I and II

• Long-term survival reasonable Patients are usually > 65 years and generally achieve

near life expectancy• Repairs are reliable

Few late events or secondary reinterventions

Conclusions

Thank You!

Joseph S. Coselli, M.D. Outcomes of 3309 Thoracoabdominal Aortic Aneurysm Repairs 95 th Annual Meeting, American Association of Thoracic Surgery (AATS)

Documents

md slide

aortic dissection

median age

patient characteristics

extent of repair p

y iqr range

connective tissue disorder

stanley crawford