Joseph S. Coselli, M.D.Joseph S. Coselli, M.D.Vice Chair, Department of Surgery

Professor, Chief, and Cullen Foundation Endowed Chair

Division of Cardiothoracic SurgeryDivision of Cardiothoracic Surgery

Baylor College of Medicine

The Houston Aortic Symposium: Frontiers in Cardiovascular DiseasesHouston, Texas • Friday, February 24, 2017Houston, Texas • Friday, February 24, 2017

Me dtronic, Inc PI ClinicalTrialsConsultant

Vascute k ConsultantVascute kTe rum o

ConsultantPI ClinicalTrialsRoy altie sCose llib ranch e d graft

W L Gore &Associate s

PI ClinicalTrialsConsultant

Bolton Me dical PI ClinicalTrialsBolton Me dical PI ClinicalTrials

• Estimated 10.4 cases per• Estimated 10.4 cases per100,000 per year Clouse et al JAMA 1998

• Without repair patients remain• Without repair patients remainat risk of aortic dissection,rupture, or bothrupture, or both Repair indicated if symptomatic

Or if a diameter-based thresholdof repair is reachedof repair is reached

> 5.5 cm in chronic dissection

> 6.0 cm for aneurysm without > 6.0 cm for aneurysm withoutaortic dissection

• However, repair itself risks• However, repair itself risksischemic and other damage todownstream organs Spinal cord Spinal cord

Kidneys

Visceral organs Visceral organs

• Organ failure may lead to deathor a life-altering complication Paraplegia/paraparesis

Renal failure necessitating dialysis

Bowel ischemia Bowel ischemia

Other

Thoracoabdominal Aortic Aneurysms:Survival with Non-operative Management

From Date of Diagnosis

From Date of AdmissionFrom Date of Admission

Crawford & DeNatale 1986TAAA: Observations Regarding the Natural Course of Disease

Crawford –1509 TAAA repairsSvensson et al. J Vasc Surg 1993Svensson et al. J Vasc Surg 1993

Lifetime Experience

31-year experience31-year experience1960 to 1991 n (%)

Early death 123 (8%)

I → 378 patients

Paraplegia/-esis 234 (16%)

Renal dialysis 136 (9%)

GI complications 101 (7%)II → 442 patients

III → 343 patients

IV → 346 patients

GI complications 101 (7%)

Svensson, Crawford, Hess, Coselli, SafiJVasc S u rg1993;17:357-70.

RiskVaries by ExtentofRepairRiskVaries by ExtentofRepair

All extents

• Moderate heparinization• Moderate heparinization

• Permissive mild hypothermia

• Aggressive reattachment ofsegmental arteriessegmental arteries

• Cold renal perfusion wheneverrenal ostia can be accessedrenal ostia can be accessed

• Expeditious repair

Extent I and II repairsExtent I and II repairs

• Cerebrospinal fluid drainage

• Left heart bypass• Left heart bypass

• Selective celiac/SMA perfusion

Left Heart Bypass

Left inferiorpulmonary vein

Distal descendingthoracic aorta

Reattachment of ICAs

Cold Renal Perfusion

9-Fr Pruitt catheters9-Fr Pruitt cathetersLR + 12.5 g/L Mannitol

+ 125 mg/L methylprednisolone

Selective Visceral Perfusion

9-Fr Pruitt catheters200-300 mL/min

Stent

B ranc hed grafts avoid latervisc eralpatc haneu rysmsvisc eralpatc haneu rysms

Red u c es native aortictissu e in M arfan synd rome

Usefu lifvisc eralarteries Usefu lifvisc eralarteriesare wid ely d isplac ed , su c has is c ommon in c hronicaortic d issec tion

Outcomes of 3309ThoracoabdominalOutcomes of 3309Thoracoabdominal

Aortic Aneurysm Repairs?Aortic Aneurysm Repairs

Coselli et al JTCVS 2016

95th Annual Meeting, American Association of Thoracic Surgery (AATS)95th Annual Meeting, American Association of Thoracic Surgery (AATS)Plenary Scientific Session: Abstract 1

Seattle, Washington • Monday, April 27, 2015

October 1986 to December 2014October 1986 to December 2014

Study Enrollment• Clinical research protocol• Clinical research protocol

approved by Baylor College ofMedicine in 2006Medicine in 2006

• Prospective data from 2006

• Retrospective data before 2006• Retrospective data before 2006

• Single-practice seriesCosellli et alOutcom e sof 3309 th oracoab dom inalaortic ane ury sm re p airsaortic ane ury sm re p airsJ Th orac Cardiovasc Surg2016;151:1323-38.

Coselli Experience

~30 year experience

3309 open TAAA repairsCoselli Experience

~30 year experience1986 to 2014 n (%)

Operative death 249 (7.5%)Operative death 249 (7.5%)

30-day death 159 (4.8%)

Permanent paraplegia 97 (2.9%)Permanent paraplegia 97 (2.9%)

Permanent paraparesis 81 (2.4%)

Renal failure (dialysis) 189 (5.7%)Renal failure (dialysis) 189 (5.7%)

Gastrointestinal ischemia 31 (0.9%)

3309 TAAA RepairsSelect Rates of Operative MortalitySelect Rates of Operative Mortality

Early DeathS u bgrou ps ofinterest n

Early Deathn (%) P

Patients ≤ 50 y 439 14 (3.2%) <.001

Patients > 79 y 193 37 (19.2%) <.001

Connective tissue disorder 330 10 (3.0%) .001

Chronic aortic dissection 1020 58 (5.7%) .007Chronic aortic dissection 1020 58 (5.7%) .007

Rupture 170 37 (21.8%) <.001

Prior aortic repair 858 70 (8.2%) .4Prior aortic repair 858 70 (8.2%) .4

Elective repair 2586 161 (6.2%) <.001

Urgent or emergent repair 723 88 (12.2%) <.001Urgent or emergent repair 723 88 (12.2%) <.001

Thoracoabdominal Aortic Aneurysms:Predictors: Multivariate Analysis

O perative M ortality RRR p value

Predictors: Multivariate Analysis

O perative M ortality RRR p value

Age (by inc reasingyear) 1.05 <.001

Clamp time (by inc reasingmin) 1.01 <.001Clamp time (by inc reasingmin) 1.01 <.001

Rupture 2.38 <.001

Renal insufficiency 1.98 .02Renal insufficiency 1.98 .02

Symptomatic aneurysm 1.62 .004

Endarterectomy, stent, or bypass 1.46 <.001Endarterectomy, stent, or bypass 1.46 <.001

Extent IV repair 0.50 0.001

0.17

3309 TAAA Repair: Risk of Operative Death

0.13

0.17

Age

Endarterectomy/stenting/bypass

Symptoms

0.11

0.13Symptoms

Renal insufficiency

Rupture

Symptoms + renal insufficiency

0.06

0.090.09Symptoms + renal insufficiency

0.06

Probability

Coselli et al 2016 JTCVS

10 20 30 40 50 60 70 80 90

Age at time of repair

O c tober1 9 8 6 to D ec ember2 0 1 4O c tober1 9 8 6 to D ec ember2 0 1 4

Gap of ≥ 50 Date 1 Date 2 Sequential cases without paraplegia1 Oct 1991 May 1992 69

2 May 1992 Nov 1992 512 May 1992 Nov 1992 51

3 July 1993 Apr 1995 261

4 Apr 1995 Oct 1995 92

5 Sep 1996 May 1997 1175 Sep 1996 May 1997 117

6 Apr 1998 Feb 1999 113

7 Feb 1999 May 1999 51

8 May 2000 Aug 2000 608 May 2000 Aug 2000 60

9 Dec 2000 Apr 2001 53

10 Feb 2002 July 2002 84

11 July 2002 Feb 2003 10211 July 2002 Feb 2003 102

12 Nov 2003 Apr 2004 65

13 June 2004 Dec 2004 62

14 Jan 2007 Dec 2007 9014 Jan 2007 Dec 2007 90

15 Dec 2010 May 2011 50

16 Mar 2014 Dec 2014 67

3470 Open ThoracoabdominalAortic Aneurysm RepairsAortic Aneurysm RepairsRepairs performed between 1 9 8 6 and Janu ary 2 0 1 7

P atientC harac teristic s n (%)P atientC harac teristic s n (%)Median age, y [IQR]; range 12 y to 92 67 [59-73]

Connective tissue disorder 357 (10%)

Marfan syndrome 313 (9%)

Aortic dissection involving distal aorta 1225 (35%)Aortic dissection involving distal aorta 1225 (35%)

Acute or subacute dissection 171 (5%)

Chronic dissection 1051 (30%)Chronic dissection 1051 (30%)

Symptomatic 2220 (64%)

Rupture 179 (5%)Rupture 179 (5%)

3470 Open ThoracoabdominalAortic Aneurysm Repairs

O perative D etails n (%)

Aortic Aneurysm RepairsRepairs performed between 1 9 8 6 and Janu ary 2 0 1 7

O perative D etails n (%)Elective repair 2696 (78%)

Urgent repair 463 (13%)

Emergent repair 311 (9%)

Reoperation* 848 (24%)

Reverse elephant trunk 84 (2%)

Completion elephant trunk 152 (4%)Completion elephant trunk 152 (4%)

Clamping proximal to theleft subclavian artery (LSCA)

553 (16%)left subclavian artery (LSCA)

*Prior open descending thoracic, thoracoabdominal, or abdominal aortic repair

27% 33% 20% 20%

3470 Open ThoracoabdominalAortic Aneurysm Repairs

Use ofO perative A d ju nc ts n (%)

Aortic Aneurysm RepairsRepairs performed between 1 9 8 6 and Janu ary 2 0 1 7

Use ofO perative A d ju nc ts n (%)Left heart bypass (distal aortic perfusion) 1566 (45%)

Hypothermic circulatory arrest 57 (2%)

Cerebrospinal fluid drainage 1641 (47%)

Cold renal perfusion 2048 (59%)

Selective visceral perfusion 833 (24%)

3470 Open ThoracoabdominalAortic Aneurysm Repairs

A d d itionalP roc ed u res n (%)

Aortic Aneurysm RepairsRepairs performed between 1 9 8 6 and Janu ary 2 0 1 7

A d d itionalP roc ed u res n (%)Reattachment of intercostal arteries 1669 (48%)

Management of visceral/renal arteries

Endarterectomy 904 (26%)

Stenting 287 (8%)

Bypass 913 (26%)

Use of a 4-branched TAAA graft 193 (6%)Use of a 4-branched TAAA graft 193 (6%)

Any visceral/renal artery procedure 1463 (42%)

3470 Open ThoracoabdominalAortic Aneurysm Repairs

Early O u tc omes n (%)

Aortic Aneurysm RepairsRepairs performed between 1 9 8 6 and Janu ary 2 0 1 7

Early O u tc omes n (%)Operative mortality 268 (8%)

30-day death 177 (5%)

Persistent*

Paraplegia 103 (3%)

Paraparesis 82 (2%)

Stroke 81 (2%)Stroke 81 (2%)

Renal failure necessitating dialysis 198 (6%)

Adverse event (composite endpoint) 504 (15%)Adverse event (composite endpoint) 504 (15%)

*Persisting to the time of hospital discharge or early death

3 4 7 0 TA A A RepairsEarly O u tc omes by ExtentofRepair

OperativeMortality

AdverseEvent

PersistentParaplegia

Early O u tc omes by ExtentofRepair

ExtentMortality

n (%)Eventn (%)

Paraplegian (%)

I 55 (6%) 103 (11%) 13 (2%)I(n=946)

55 (6%) 103 (11%) 13 (2%)

II(n=1130)

114 (10%) 217 (19 %) 53 (5%)(n=1130)

114 (10%) 217 (19 %) 53 (5%)

III(n=692)

58 (8%) 115 (17%) 31 (5%)

IV(n=702)

41 (6%) 69 (10%) 6 (1%)

Total 268 (8%) 504 (15%) 103 (3%)Total(n=3470)

268 (8%) 504 (15%) 103 (3%)

• Much work remains to be done• Much work remains to be done

• Contemporary TAAA open repair yields• Contemporary TAAA open repair yieldsgood-to-excellent outcomes inexperienced centersexperienced centers

• Variety of adjuncts have lowered risk in• Variety of adjuncts have lowered risk incontemporary practice

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