Home Random Page



Outcome and Prognosis

According to Culliford et al from 1982,[40] Cabrol et al from 1988,[41] and Donaldson and Ross from 1982,[42] the early hospital mortality rate following repair of ascending aneurysms is 4-10%. Contemporary surgical series demonstrated a continued wide range in operative mortality (2-17%). Stroke occurs in 2-5% of patients.

As would be expected, the early mortality rate after repair of arch aneurysms is considerably higher, approaching 25% in series by Crawford and Saleh from 1981,[43] by Crawford et al from 1979,[44] by Columbi et al from 1983,[45]by Ergin et al from 1982,[46] and by Galloway et al from 1989.[47] More contemporary results from Coselli and Ueda demonstrate operative mortality of 6-12%. Stroke rate varied from 3-22%. Renal failure that required dialysis occurred in 7% of patients.

The mortality rate after repair of descending thoracic aneurysms is lower, approximately 5-15% according to Crawford et al from 1981,[43] to Donahoo et al from 1977,[48] to Livesay et al from 1985,[49] and to Pressler and McNamara from 1985.[2] Contemporary results are unchanged, with 12-15% mortality.

As a group, including all repairs, according to Crawford et al from 1978,[50]Crawford et al from 1981,[43] and Kitamura et al from 1983,[51] survival rates after surgery for chronic aortic aneurysms are approximately 60% at 5 years and 30-40% at 10 years.

The longest follow-up data for a multicenter trial comparing endovascular and open techniques for management of thoracic aortic aneurysms are the results of a phase II multicenter trial for the GORE-TAG thoracic endovascular stent. A 1.5% 30-day mortality for endovascular repairs was demonstrated, temporary or permanent spinal cord paraplegia occurred in 3% of patients and stroke in 4% of patients.[52] At 2 years, aneurysm survival was 97% and overall survival 75%.[52] For the Medtronic Talent device, the incidence of paraplegia in the stent group was 0-9%, stroke 3.7-8.1%, 30-day mortality 2.9-9.7%, and procedural success of more than 95%.[28]

When endovascular stent grafting was compared with open surgery for the GORE-TAG device, the rate of paraplegia was 3% in the stent group vs 14% in the open group;[26] operative mortality was 1% vs 6%, and early death was 2% vs 10%.[53] The patients in the stent group had a shorter ICU and hospital stay, a quicker recovery time, and a lower incidence of major adverse events (except for vascular complications). Complications at 2 years included 4% proximal stent migration, 6% migration of the graft components, and 15% of patients had an endoleak.

Overall, survival rates were equivalent between the endovascular and open groups at both 2-years and 5-years, 80% and 70% respectively, but aneurysm-related survival significantly favored endovascular repairs at 5 years (97% vs 88%).[54] However, more contemporary "real world" experienced application has not been as supportive of this discrepancy as noted by Greenberg et al where no significant difference between mortality or paraplegia was discerned in their population at 30 days (5.7 vs 8.3%) nor at one year (15.6% vs 15.9%).[55]

Midterm results comparing open descending thoracic aneurysm repair with endovascular stent grafting demonstrate less early operative mortality with endovascular repair (10% for stent grafting vs 15% for open repair) but similar late survival (actuarial survival rate at 48 months of 54% for stent grafting vs 64% for open repair).

Success with the results of endovascular repair of contained, degenerative thoracic aortic aneurysms of the descending aorta have created an environment to use endografts for treatment of arch aneurysms as well as acute catastrophes of both the arch and descending aortas.

Recently, data from a multi-center, nonrandomized, prospective study of the use of endografts in emergent pathologies of the descending aorta was published.[56] In situations that have reported mortality rates as high as 90%, the authors found that in the management of acute type B dissections, traumatic aortic tears, or ruptured aortic aneurysms, endovascular management compared to open resulted in a 14% vs 30% 30-day composite mortality/paraplegia rate.

Although, freedom from aortic related events was 84.5% at one-year for the endovascular cohort, survival was only 66% with the subset of ruptured aneurysms have the worst survival (37%). Another multicenter trial evaluating use in ruptured aneurysms confirmed the perioperative mortality rate, but also noted considerable neurological complications (8%), procedure-related complications such as endoleak (18%) and ongoing aneurysm related death, 25% at 4 years.[57]

Others have used endografts for arch pathologies, which usually necessitates a "hybrid" approach, a combination of endovascular and open techniques. Small (< 30 patients), single institution series, with limited followup have reported perioperative mortality, stroke and paraplegia rates 0-25%, 0-25%, and 0-4% respectively, questioning the durability and futility of the repairs.[58, 59] However, a series from a single, tertiary care medical center highlighted the results of 400 consecutive patients, demonstrating a 6.5% and 53% 30day and 4-year mortality, respectively, and a paraplegia and stroke rate of 4.5% and 3%, respectively.[60]

Date: 2015-12-11; view: 581

<== previous page | next page ==>
Postoperative Details | Increase your Word Power
doclecture.net - lectures - 2014-2022 year. Copyright infringement or personal data (0.002 sec.)