Endovascular treatment versus conventional surgery of the thoracic aorta in patients with previous repair of abdominal aortic aneurysm

Objectives: Descending aortic aneurysm repair in patients after previous abdominal aortic aneurysm (AAA) surgery have a high risk for spinal cord ischemia and renal dysfunction. This study evaluates the morbidity and mortality after thoracic stent implantation and conventional descending aneurysm surgery in patients with prior AAA repair.

Methods: Retrospectively, 63 patients with previous AAA repair were identified. In 29 patients (24 male, mean age 71 years, range 58–84 years) thoracic endografts were implanted (8 emergency). In the surgical group we included 20 patients (17 male, mean age 69 years, range 53–82 years) with descending aortic replacement above the diaphragm comparable with the endovascular group. There were 10 emergency procedures.

Results: The mean time interval between prior AAA repair and subsequent thoracic procedure was 5.5 years (125 days to 17 years) for stent implantation and 5.7 years (16 days to 13 years) for surgical repair. Thoracic stent placement was successful in all patients. In 5 patients the left subclavian artery was occluded. The 30-day mortality was 6.8% (2/29 pts.) in the endovascular group and 15% (3/20 pts.) in the surgical group. The rate of postoperative neurological complications differed but without statistical significance, whereas the postoperative creatinine level and new onset renal failure requiring hemodialysis differed significantly between the groups (Table).

Table 1

Variables	Endovascular group (n=29)	Surgical group (n=20)	p value
Age (mean±SD)	71±6.4	69±6.4	n.s.
Sex (male/female)	24/5	16/4	n.s.
Creatinine (mg/dl) Preop./Postop. (mean±SD)	1.57±1.4/1.92±1.7	1.42±0.5/2.3±1.2	n.s./0.04
Postop. dialyses, n (%)	1 (3.4)	6 (30)	0.02
Median Intubation time, h (range)	6 (3–720)	60 (24–1560)	<0.001
Pulmonary infection, n (%)	1 (3.4%)	4 (20%)	n.s.
Blood transfusion (ml) (mean±SD)	249±456	2126±1809	<0.01
Neurological complications, n (%)	2 (6.8%)	3 (15%)	n.s.
30-day mortality, n (%)	2 (6.8%)	3 (15%)	n.s.

Conclusions: Thoracic stent implantation in patients after previous abdominal aortic aneurysm surgery can be performed without technical problems. In comparison to patients with conventional repair, those with endovascular stent implantation have a statistically significantly lower risk of renal failure and shorter intubation time. Although no statistical difference is present, the early outcome of endovascular graft treatment appears to be better than that of conventional surgical repair, also in respect to neurological complications and mortality.