Virendra I. Patel, MD MPH

Associate Professor of SurgeryVascular Surgery and Endovascular Interventions

Extracorporeal bypass use improves

outcomes of open thoracic and

thoracoabdominal aneurysm repair

Speaker name:

Virendra I. Patel MD MPH

I have the following potential conflicts of interest to report:

Consulting

Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company

Other(s)

I do not have any potential conflict of interestX

Disclosures

Background

•Use of extracorporeal circulation (EC) during descending thoracic aneurysm (DTA) and thoraco-abdominal aneurysm (TAA) repair is variable

Neuro: Decreased SCI

CV: Decreased afterload

LV function / aortic insufficiency

Organs: Improved perfusion

Decreased visceral ischemia

Ann Surg 2003;238:372-381

• Use of adjuncts independently reduced the risk of

mortality and morbidity

• Advocate use of distal perfusion in all TAA types

• SCI 2.4%

Distal aortic perfusion

Recent Results

J Vasc Surgery 2013; 58:283-290

VariableClamp/Sew

(n=385)

DAP/MEVOP

(n=100)p

Post-op Death 9.9% 4.0% 0.072

Permanent SCI 11.9% 3.0% 0.008

Perm SCI/Death 19.1% 7.0% 0.003

ARF with HD 11.4% 5.1% 0.063

0 1 2 3 4 5 6 7

0

20

40

60

80

100

AFB/MEVP

Clamp/Sew

Survival

Years

% S

urv

iva

l

Ann Thorac Surg 2007;83:S862-4

• Largest published series

• Selective left heart bypass use (~40%)

• 5% Mortality / 5% SCI

Specific Aims

• Evaluate the impact of EC use during DTA

and TAA repair in the US Medicare

population

Study Design and Cohort

• Retrospective cohort study

• Medicare Provider Analysis and Review (2004-2007)

• Medicare Part A claims

• Linkage to Vital Statistics for mortality and long

term survival analysis

Study Design and Cohort

Non-ruptured open thoracic aortic repairs by ICD-9

(N=18,282)

Specific exclusions applied:

→ Cardiac revasc., cardioplegia, valve procedures

(N=10,658)

→ Deep hypothermic circulatory arrest

(N=116)

→ No diagnosis of DTA or TAA

(N=3278)

Study Design and Cohort

The entire cohort of DTA/TAA (N=4230)

Stratified by use of EC (ICD-9 39.61):

Extracorporeal Circulation (EC) (N=2433)

No Bypass (N=1797)

Study Design

Study Endpoints:

- 30 day death and late survival

- Systemic complications

- Predictors of death or systemic complications

- Long-term survival

- Predictors of late mortality

Clinical Features

VariableNo EC

(N=1997)

EC

(N=2433)P Value

Age (years) 72 ± 8 72.5 ± 8 0.002

Female 47% 53%

Peri-operative Outcomes

VariableNo EC

(N=1997)

EC

(N=2433)P Value

Death 12.2 % 9.7 % 0.01

Any complication 58% 49%

Peri-operative Outcomes Cont.

VariableNo EC

(N=1997)

EC

(N=2433)P Value

LOS11

(8,20)

9

(7,16)

Multivariable Models – 30 day

Variable

Extracorporeal

Circulation

OR [95% CI]

P Value

Death 0.8 [0.65-0.97] 0.02

Any Comp. 0.67 [0.65-0.97]

Long-term Survival

67 ± 1%

52 ± 2%

Survival Models

VariableDeath

HR[95% CI]P Value

Extracorporeal

circulation0.69 [0.63-0.74] < 0.0001

Post-op.

complications2.4 [2.1-2.7]

< 0.0001

Other predictors: age, race, COPD, CeVD, CKD

Summary

EC use during TAA/TAAA repair is associated with:

- Lower 30 day mortality

- Lower 30 day resp, renal, bleeding complications

- Decreased cost

- Improved long term survival

Conclusion

• Unless contra-indicated for technical or clinical reasons, EC should be utilized as

an adjunct during DTA and TAA repair

Thank You

Aortic Center

1-800-RxAortawww.columbiasurgery.org/aortic

Virendra I. Patel, MD MPH

Associate Professor of SurgeryVascular Surgery and Endovascular Interventions

Extracorporeal bypass use improves

outcomes of open thoracic and

thoracoabdominal aneurysm repair