Open thoracic or thoracoabdominal aortic aneurysm repair after previous abdominal aortic aneurysm surgery

Objective: The purpose of this study was to provide insight into the incidence of thoracic and thoracoabdominal aortic aneurysm repair following previous infrarenal abdominal aortic aneurysm (AAA) surgery and to determine whether thoracic or thoracoabdominal aortic aneurysm repair after prior infrarenal AAA surgery is associated with higher mortality and morbidity rates. Methods: MEDLINE, Cochrane Library CENTRAL, and EMBASE databases were searched for relevant articles. Selected articles were critically appraised and meta-analyses were performed. Results: A total of 12.4% of patients with thoracic aortic aneurysms and 18.7% of patients with thoracoabdominal aortic aneurysms have had prior AAA surgery. The chance of developing a thoracic aortic aneurysm in patients with AAA is 2.2% and 2.5% for developing a thoracoabdominal aortic aneurysm. The mean time interval between prior AAA surgery and subsequent thoracoabdominal aortic aneurysm surgery or detection is 8.0 years with a wide variation between individuals. Surgery in these patients is technically feasible. The 30-day mortality of patients undergoing open thoracoabdominal aortic aneurysm repair does not significantly differ from patients without prior AAA surgery and the 30-day mortality is 11.8%. No data were available about mortality of patients with prior AAA repair undergoing thoracic aortic aneurysm surgery. Morbidity risks are higher in patients with thoracic or thoracoabdominal aortic aneurysms. Prior AAA repair was a significant risk factor for neurological deficit after thoracic or thoracoabdominal aortic aneurysms surgery with relative risks (RRs) of 11.1 (95% confidence interval [CI] 3.8-32.3, P value < .0001) and 2.90 (95% CI 1.26-6.65, P value = .008), respectively. Prior AAA repair was a significant risk factor for developing renal failure in patients undergoing thoracoabdominal aortic aneurysm repair (RR 3.47, 95% CI 1.74-6.91, P value = .0001). Determinants of the prognosis in these patients include distal aortic perfusion, distal extent of the landing zone of the graft, drainage of cerebrospinal fluid for thoracic aortic aneurysm repair and age, history of cardiac diseases, extent of the aneurysm, rupture, amount of estimated blood loss, aortic clamp time, and visceral ischemic times for thoracoabdominal aortic aneurysm repair. Conclusions: A considerable group of patients with thoracic or thoracoabdominal aortic aneurysms have had prior AAA repair. The risk of postoperative morbidity is increased in these patients. Mortality appears to be similar for patients with thoracoabdominal aortic aneurysms. Patients with prior AAA repair undergoing thoracic or thoracoabdominal aortic aneurysm repair should be provided maximum care to protect their spinal cord and renal function.

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