Further experience with distal aortic perfusion and motor-evoked potential monitoring in the management of extent I-III thoracoabdominal aortic anuerysms

Background: Prior studies indicated improved early mortality and paraplegia rates in a small cohort of patients with type I-III thoracoabdominal aortic aneurysms (TAAs) treated with atriofemoral bypass (AFB) and motor-evoked potentials (MEVPs) when compared with a propensity-matched cohort of patients treated with the clamp and sew (CS) method, wherein epidural cooling was the principal spinal cord protective adjunct. The use of AFB/MEVP increases the complexity of TAA repair and in this study, we address whether the early benefits will be sustained when this is applied to a general population with type I-III TAAs. Methods: Consecutive patients undergoing repair of nonruptured Crawford extent I-III TAAs from 1/1987 to 12/2011 were identified. Patients were stratified according to operative approach (AFB/MEVP vs CS). Endpoints included long-term survival, and the composite outcome of perioperative death and paraplegia. A multivariate, risk-adjusted model was then created to determine if operative approach independently influenced outcome. Results: There were 485 patients (CS = 385 [79%]; AFB/MEVP = 100 [21%]). The cohorts differed in that the AFB/MEVP group was younger (65.8 +/- 12.5 years vs 70.9 +/- 9.7 years; P < .001), had more extent I/II aneurysms (66% vs 50.1%; P = .005), and had more chronic dissections (30.3% vs 18.9%; P = .018). Operative variables differed in that the AFB/MEVP cohort had longer operative times (434 +/- 112 minutes vs 324 +/- 98 minutes; P < .001) and higher blood turnover (6028 +/- 3473 mL vs 3581 +/- 3111 mL; P < .0001). There was no difference in the rate of intraoperative death (AFB/MEVP = 1.0% vs CS = 0.5%; P = .50), length of intensive care unit stay (AFB/MEVP = 9.6 +/- 8.6 days vs CS = 9.5 +/- 12.3 days; P = .95) or hospital length of stay (AFB/MEVP = 19.9 +/- 12.6 days vs CS = 21.6 +/- 23.5 days; P = .49). The composite perioperative death and paraplegia rate was lower in the AFB/MEVP cohort (7% vs 19%; P = .004). The multivariate model for predictors of the composite outcome showed that AFB/MEVP was protective (odds ratio, 0.39; 95% confidence interval, 0.17-0.9; P = .028). Long-term (4-year) survival was improved in the AFB/MEVP group as well (73 +/- 6% vs 60 +/- 3%; P = .004). Conclusions: AFB/MEVP is an independent predictor of improved perioperative death and paraplegia rates as well as long-term survival in patients undergoing repair of type I-III TAAs and is the preferred operative strategy.