eMedicine Specialties > Thoracic Surgery > Vascular

Thoracic Aortic Aneurysm: Follow-up

Author: Elaine Tseng, MD, Assistant Professor of Surgery, Division of Cardiothoracic Surgery, University of California at San Francisco
Coauthor(s): Mabelle H Cohen, MD, Fellow, Department of Cardiothoracic Surgery, University of California, San Francisco
Contributor Information and Disclosures

Updated: Nov 17, 2009

Outcome and Prognosis

According to Culliford et al from 1982,32 Cabrol et al from 1988,33 and Donaldson and Ross from 1982,34 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 1981,35 by Crawford et al from 1979,36 by Columbi et al from 1983,37 by Ergin et al from 1982,38 and by Galloway et al from 1989.39 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 1981,35 to Donahoo et al from 1977,40 to Livesay et al from 1985,41 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 1978,42 Crawford et al from 1981,35 and Kitamura et al from 1983,43 survival rates after surgery for chronic aortic aneurysms are approximately 60% at 5 years and 30-40% at 10 years.

The results of a phase II multicenter trial for the GORE-TAG thoracic endovascular stent demonstrated 1.5% 30-day mortality. Temporary or permanent spinal cord paraplegia occurred in 3% of patients and stroke in 4% of patients.44 At 2 years, aneurysm survival was 97% and overall survival 75%.44 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 >95%.26

When endovascular stent grafting was compared to open surgery for the GORE-TAG device, the rate of paraplegia was 3% in the stent group vs 14% in the open group;24 operative mortality was 1% vs 6%, and early death was 2% vs 10%.45 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. Survival rates were the same (80% in both the open and stent groups).

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).

Future and Controversies

Ascending aortic aneurysm repair has been well established and is performed safely with low morbidity and mortality. The controversies lie in the use of valve-sparing root replacements in patients with Marfan syndrome with regard to the durability of the repair. However, because most patients with Marfan syndrome undergo the operation while they are young, they likely require reoperation eventually and the additional years of sparing their native aortic valve and living without anticoagulation are valuable.
 
Arch aneurysms still carry the most morbidity and mortality because neurologic injury is a great risk. Most controversies involve the methods of cerebral protection. More and more evidence suggests that antegrade cerebral perfusion is an optimal choice to reduce both temporary and permanent neurologic injury.
 
Recent advances in the treatment of descending thoracic aneurysms and thoracoabdominal aneurysms have used endovascular stent grafting, which offers a less invasive alternative to open surgical repair. The first FDA-approved device for descending thoracic aneurysm repair was approved in March 2005. The nonrandomized prospective comparison of open surgical versus endovascular stenting demonstrated a reduced incidence of operative mortality and reductions in paraplegia, blood loss, operative time, and length of ICU stay. The incidence of stroke between the two groups was similar.
 
Midterm results suggest that, although early operative mortality rates are lower with endovascular repair than with open surgical repair, late survival rates are equivalent. Paraplegia rates in the real world (as opposed to in carefully selected patient populations of clinical trials) suggest an increased incidence of paraplegia with endovascular stent grafting but range from 0-12% (average 2.7%).
 
Future studies will examine comparisons of open versus endovascular repair of thoracoabdominal aneurysms and aortic arch aneurysms.

Aneurysms are the most commonly diagnosed conditions of the thoracic aorta that require surgery. Recently, many advances in aortic substitutes, cerebral protection, and perioperative care have led to improved survival rates and outcomes.

 


More on Thoracic Aortic Aneurysm

Overview: Thoracic Aortic Aneurysm
Workup: Thoracic Aortic Aneurysm
Treatment: Thoracic Aortic Aneurysm
Follow-up: Thoracic Aortic Aneurysm
References
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References

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Further Reading

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Keywords

thoracic aortic aneurysm, aortic aneurysm, ascending thoracic aortic aneurysm, thoracic aortic aneurysm repair, aneurysm repair, descending thoracic aortic aneurysm, abdominal aortic aneurysm, thoracic aneurysm, thoracoabdominal aneurysm, aneurysm rupture

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Contributor Information and Disclosures

Author

Elaine Tseng, MD, Assistant Professor of Surgery, Division of Cardiothoracic Surgery, University of California at San Francisco
Elaine Tseng, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Mabelle H Cohen, MD, Fellow, Department of Cardiothoracic Surgery, University of California, San Francisco
Mabelle H Cohen, MD is a member of the following medical societies: American College of Surgeons and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Benson B Roe, MD, Emeritus Chief, Division of Cardiothoracic Surgery, Emeritus Professor, Department of Surgery, University of California at San Francisco Medical Center
Benson B Roe, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Surgeons, American Heart Association, American Medical Association, American Society for Artificial Internal Organs, American Surgical Association, California Medical Association, Society for Vascular Surgery, Society of Thoracic Surgeons, and Society of University Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Shreekanth V Karwande, MBBS, Chair, Professor, Department of Surgery, Division of Cardiothoracic Surgery, University of Utah School of Medicine and Medical Center
Shreekanth V Karwande, MBBS is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Heart Association, Society of Critical Care Medicine, Society of Thoracic Surgeons, and Western Thoracic Surgical Association
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

Mary C Mancini, MD, PhD, Professor and Chief, Cardiothoracic Surgery, Department of Surgery, Louisiana State University Health Sciences Center-Shreveport
Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons, and Southern Surgical Association
Disclosure: Nothing to disclose.

 
 
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