Operative times and outcomes of complex endovascular repairs of thoracoabdominal aneurysms.

Abstract

Background: Owing to the significant morbidity and mortality of open thoracoabdominal aortic aneurysm surgery, complex endovascular repairs have become increasingly common, but still carry substantial risk. These repairs require large-bore access, with resultant pelvic and lower extremity ischemia. We, therefore, hypothesized that operative timing would be associated with outcomes, because efficient surgery would limit the ischemic time as well as anesthesia time.

Methods: We studied all thoracoabdominal aortic aneurysm surgerywith complex endovascular repairs (Crawford types 1, 2, 3, and 5) incorporating at least one branch vessel from 2014 to 2021 in the Vascular Quality Initiative and categorized them into quartiles of total operating time. To account for variations in case complexity and intraoperative events, we performed a subanalysis stratifying each surgeon by their median operating time. Multilevel logistic regression was used to compare perioperative outcomes including mortality, thoracoabdominal life-altering events (a composite of perioperative death, stroke, permanent paralysis and/or dialysis), spinal cord ischemia (SCI), acute kidney injury, major adverse cardiac events, myocardial infarction, and dialysis.

Results: There were 2925 thoracoabdominal aortic aneurysm surgery with complex endovascular repairs during the study period. Procedure times ranged from <204 minutes in the first quartile to >365 minutes in the fourth. Longer cases more commonly involved older patients who were more often female and higher rates of prior stroke and preoperative anemia. They involved larger, more extensive aneurysms, with higher rates of prior aortic surgery, and more commonly used physician-modified endografts or parallel grafting to incorporate more branch vessels. In addition, they were less often staged procedures, and used more spinal drains, femoral cutdowns, and upper extremity access. Operating time decreased as experience increased. In adjusted analyses, the odds of mortality and every morbidity studied increased stepwise with operating time, with 4- to 13-fold higher odds in the highest quartiles. SCI had the strongest association with procedure times, with seven-fold higher odds (odds ratio, 7.2; 95% confidence interval, 2.9-17.9; P < .001) of any SCI in the highest quartile compared to the lowest, and 13-fold higher odds of permanent SCI (OR, 13.1; 95% confidence interval, 3.9-44.7; P < .001). These results were consistent when surgeons were grouped into quartiles by their median operating times. Medium-term mortality was also higher in the upper quartile of operating time (hazard ratio, 2.7; 95% confidence interval, 1.4-5.1; P = .002).

Conclusions: Longer operating times for complex thoracoabdominal aortic aneurysm surgerywith complex endovascular repairs were associated with markedly higher rates of morbidity and mortality, especially SCI. These results emphasize the importance of expeditious repairs by experienced teams.