Surgery for ruptured thoracic and thoraco-abdominal aortic aneurysms

Objective. To assess the outcome of patients with ruptured descending thoracic and thoracoabdominal aortic aneurysms undergoing emergency repair, in comparison to elective surgery for chronic lesions. Methods. A prospective study of 100 consecutive patients operated upon the descending aorta (1-8 segments) using proximal unloading and distal protection with partial cardiopulmonary bypass, heparin surface-coated perfusion equipment and low systemic heparinization (loading dose 100 IU/kg, activated coagulation time >180 s), staged crossclamping, sealed grafts and graft inclusion. Results. Arteriosclerotic lesions were present in 53/100 patients (53%) for all, 30/53 (56%) for chronic, and 21/33 (63%) for ruptured, aneurysms (NS). Dissecting lesions were found in 38/100 patients (38%) for all, 20/53 (38%) for chronic, and 8/33 (24%) for ruptured aneurysms (NS). Preoperative hematocrit was 38+/-6% for all, 40+/-5% for chronic, and 33+/-5% for ruptured aneurysmal patients (P<0.001 ruptured versus chronic). The extent of aortic repair (1-8 segments) was 3.3+/-1.6 for all, 3.5+/-1.5 for chronic, and 3.2+/-1.4 for ruptured, aneurysms (NS). Trans diaphragmatic repair was performed in 51/100 (51%) of all, 28/53 (53%) of chronic, and 17/33 (51%) of ruptured aneurysms (NS). Aortic crossclamp time was 38+/-21 min for all, 39+/-24 min for chronic, and 38+/-17 min for ruptured, aneurysmal patients (NS). The amount of red cells washed and autotransfused was 2792+/-2239 ml in all, 3143+/-2531 mi in chronic, and 2074 +/- 1350 mi in ruptured, aneurysmal patients (P<0.025). The amount of packed red cells required was 2181+/-1830 ml for all, 1736+/-1333 mi for chronic, and 2947+/-2395 mi for ruptured aneurysmal patients (P<0.010). Thirty-day mortality was 9/100 (9%) for all, 3/53 (6%) for chronic, and 5/33 (15%) for ruptured aneurysmal patients (NS). Parapareses/plegias occurred in 9/100 (9%) of all, 6/53 (11%) of chronic, and 3/33 (9%) of ruptured, aneurysmal patients (NS). Stepwise regression analysis identified aortic cross-clamp time as a predictor of early mortality (P=0.002) and parapareses and paraplegias (P=0.001). Age (P=0.001), extent of repair (P=0.008) and preoperative hematocrit (P=0.001) were predictors for homologous transfusion requirements. Conclusion. Emergency repair of ruptured descending thoracic and thoracoabdominal aortic aneurysms can be achieved with acceptable results.