Surgery for ruptured thoracic and thoraco-abdominal aortic aneurysms

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Abstract
OBJECTIVE: To assess the outcome of patients with ruptured descendingthoracic and thoracoabdominal aortic aneurysms undergoing emergency repair,in comparison to elective surgery for chronic lesions. METHODS: Aprospective study of 100 consecutive patients operated upon the descendingaorta (1-8 segments) using proximal unloading and distal protection withpartial cardiopulmonary bypass, heparin surface-coated perfusion equipmentand low systemic heparinization (loading dose 100 IU/kg, activatedcoagulation time > 180 s), staged cross-clamping, sealed grafts andgraft inclusion. RESULTS: Arteriosclerotic lesions were present in 53/100patients (53%) for all, 30/53 (56%) for chronic, and 21/33 (63%) forruptured, aneurysms (NS). Dissecting lesions were found in 38/100 patients(38%) for all, 20/53 (38%) for chronic, and 8/33 (24%) for rupturedaneurysms (NS). Preoperative hematocrit was 38 +/- 6% for all, 40 +/- 5%for chronic, and 33 +/- 5% for ruptured aneurysmal patients (P < 0.001ruptured versus chronic). The extent of aortic repair (1-8 segments) was3.3 +/- 1.6 for all, 3.5 +/- 1.5 for chronic, and 3.2 +/- 1.4 for ruptured,aneurysms (NS). Transdiaphragmatic repair was performed in 51/100 (51%) ofall, 28/53 (53%) of chronic, and 17/33 (51%) of ruptured aneurysms (NS).Aortic cross-clamp time was 38 +/- 21 min for all, 39 +/- 24 min forchronic, and 38 +/- 17 min for ruptured, aneurysmal patients (NS). Theamount of red cells washed and autotransfused was 2792 +/- 2239 ml in all,3143 +/- 2531 ml in chronic, and 2074 +/- 1350 ml in ruptured, aneurysmalpatients (P < 0.025). The amount of packed red cells required was 2181+/- 1830 ml for all, 1736 +/- 1333 ml for chronic, and 2947 +/- 2395 ml forruptured aneurysmal patients (P < 0.010). Thirty-day mortality was 9/100(9%) for all, 3/53 (6%) for chronic, and 5/33 (15%) for ruptured aneurysmalpatients (NS). Parapareses/plegias occurred in 9/100 (9%) of all, 6/53(11%) of chronic, and 3/33 (9%) of ruptured, aneurysmal patients (NS).Stepwise regression analysis identified aortic cross- clamp time as apredictor of early mortality (P = 0.002) and parapareses and paraplegias (P= 0.001). Age (P = 0.001), extent of repair (P = 0.008) and preoperativehematocrit (P = 0.001) were predictors for homologous transfusionrequirements. CONCLUSION: Emergency repair of ruptured descending thoracicand thoracoabdominal aortic aneurysms can be achieved with acceptableresults.

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