Résultats de la chirurgie ouverte des anévrismes complexes de l'aorte abdominale

The objective was to evaluate the' morbidity and mortality of open repair for supra-renal and type IV thoracoabdominal aortic aneurysms (TAA). Material and. Methods: This single-center retrospective observational study consecutively included all patients operated from 2000 to 2021 for supra-renal aneurysm or IV TAA. The approaches were retroperitoneal +/- a complete phrenotomy. The digestive arteries and the right renal were integrated into the proximal aortic anastomosis. The left renal artery (LRA) was revascularized by anterograde, retrograde bypass or direct reimplantation. The primary endpoint was 30-day mortality. Secondary endpoints assessed in-hospital mortality, morbidity, and long-term survival. Respiratory failure was defined as intubation >24h, reintubation, or use of NIV. Statistical analyses were performed using a Mann Whitney test or Fisher test. Results: One hundred and twelve patients, mean age 68 years, were included with a mean ASA score of 2.7. LRA revascularization was anterograde (A: 31.5%), retrograde (R: 59.5%) or direct (D: 9%). The clamping times of the digestive, right and LRA were 28, 30 and 49 min, respectively. One death at 30 days from respiratory distress (0.9%). One paraplegia (0.9%). Thirty-seven patients (33%) developed respiratory failure. The occurrence of respiratory failure was not different according to whether a complete phrenotomy was performed or not (p=0.84), nor according to the type of LRA revascularization (p=0.27). In-hospital mortality was higher in patients with respiratory failure (p=0.03). Thirty-three patients (30%) had KDIGO AKI > II. Patients with KDIGO AKI > II had higher right and left renal ischemia durations (p II, was different according to the type of LRA revascularization (A: 5/36; R: 22/66 and D:6/10; p II (p=0.03). Five patients (4.5%) were dialyzed immediately postoperatively, only in the retrograde/direct bypass groups. The median survival was 12 years. It was different according to the type of LRA revascularization (p=0.03). Conclusion: The morbi-mortality of open repair of supra-renal aneurysms and IV TAA is pulmonary. It was not increased by phrenotomy or anterograde LRA repair.L'objectif est d'évaluer la morbi-mortalité de la chirurgie ouverte des anévrismes aortiques supra-rénaux et thoraco abdominaux (ATA) de type IV. Matériel et Méthodes : Cette étude observationnelle rétrospective monocentrique a inclus consécutivement l'ensemble des patients opérés de 2000 à 2021 d'un anévrisme supra-rénal ou d'un ATA IV. Les voies d'abord étaient rétro-péritonéales +/- une phrénotomie complète. Les artères digestives et la rénale droite étaient intégrées dans l'anastomose aortique proximale. L'artère rénale gauche (ARG) était revascularisée par un pontage antérograde, rétrograde ou une réimplantation directe. Le critère de jugement principal était la mortalité à 30 jours. Les critères secondaires évaluaient la mortalité intra-hospitalière, la morbidité et la survie à long terme. Une défaillance respiratoire était définie par une intubation >24h, une ré-intubation, ou le recours à la VNI. Les analyses statistiques ont été réalisées selon un test de Mann Whitney ou un test de Fisher. Résultats : Cent-douze patients, d'âge moyen 68 ans ont été inclus avec un score ASA moyen de 2,7. La revascularisation de I'ARG était antérograde (A : 31.5%), rétrograde (R : 59.5%) ou directe (D : 9%). Les durées de clampage des artères digestives, rénale droite et gauche étaient respectivement de 28, 30 et 49 mn. Un décès à 30 jours d'une détresse respiratoire (0,9%). Une paraplégie (0,9%). Trente-sept patients (33%) ont présenté une défaillance respiratoire. La survenue d'une défaillance respiratoire n'était pas différente selon la réalisation d'une phrénotomie complète ou non (p=0,84), ni selon le type de revascularisation de l'ARG (p-0,27). La mortalité intra-hospitalière était plus élevée chez les patients ayant eu une défaillance respiratoire (p-0,03). Trente-trois patients (30%) ont présenté une IRA KDIGO > II. Les patients ayant eu une IRA KDIGO > II avaient des durées d'ischémie rénale droite et gauche plus élevées (p II, était différente selon le type de revascularisation de I'ARG (A : 5/36 ; R : 22/66 et D :6 /10 ; p II (p-0,03). Cinq patients (4,5%) ont été dialysés en post-opératoire immédiat, uniquement dans les groupes pontage rétrograde/direct. La survie médiane était de 12 ans. Elle était différente selon le type de revascularisation de l'ARG (p=0,03). Conclusion : La morbi mortalité de la chirurgie ouverte des anévrismes supra-rénaux et des ATA IV est pulmonaire. Elle n'était pas augmentée par la phrénotomie ou la revascularisation antérograde de l'ARG

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International audienc

Impact of the COVID-19 Pandemic on Complex Aortic Aneurysm Surgery

International audienceIntroduction: This study aimed to evaluate the impact of COVID on total case load and peri-operative outcomes in patients undergoing open surgical repair (OSR) and endovascular repair (ER) of complex aortic aneurysms (cAAs). Methods: A single-center retrospective analysis of prospective data of patients managed with elective cAA ER or OSR from January 2018 to December 2021 was conducted. A comparative analysis on the impact of the COVID-19 pandemic on the case volume and on the 30-day outcomes was assessed using time periods, before (2018–2019) and during the pandemic (2020–2021). Results: During the 4-year study period, 255 patients with cAA were managed with ER and 576 with OSR. The pandemic did not reduce the cAA ER volume (p=0.12), but a statistically significant reduction in OSR case load was recorded (p=0.04). Following OSR, hospital length of stay (11.1 vs 10.3 days), and early mortality (6.94% vs 4.63%), were similar before and during the pandemic. In the ER cohort, baseline characteristics, early mortality (3.6% vs 4.1%, p=0.976), and morbidity (10% vs 14%, p=0.44), were comparable during the 2 periods. For ER cases, the hospital and intensive care unit (ICU) stay both decreased significantly (8±8–6±7 days, p<0.001 and 2±4 vs 1±6 days p=0.01, respectively) during the pandemic. Conclusion: Resource pressures drove modifications in clinical practice to reduce the length of hospitalization, without compromising the clinical outcomes, in patients undergoing ER of cAA. This modification was not effective in patients undergoing OSR that resulted in a significant decrease of this activity. Clinical Impact The pandemic did not reduce complex endovascular repair (ER) volume (p=0.12) while a significant reduction in open surgical repair (OSR) case load was recorded (p=0.04). For the endovascular cohort, early mortality (p=0.976) and morbidity (p=0.44) remained stable, while the hospital and intensive care unit (ICU) stay decreased (p<0.001 and p=0.01, respectively) during the pandemic

Protocol of supra-visceral aortic ischemic preconditioning for open surgical repair of thoracoabdominal aortic aneurysm: The EPICATA study (Evaluation of the Efficacy of Ischemic PreConditioning on morbidity and mortality in open ThoracoAbdominal Aortic surgery)

International audienceBackground: Open surgical repair (OSR) for thoracoabdominal aortic aneurysms (TAA) is associated with a high pulmonary and renal morbidity rate. Ischemic preconditioning (IPC) is a mechanism of protection against the deleterious effects of ischemia-reperfusion. To our knowledge IPC has never been tested during OSR for TAA.Methods: The primary objective of the study is to evaluate the efficacy of IPC during OSR for TAA with respect to acute kidney injury (AKI) according to KDIGO and pneumonia/prolonged ventilation-time during the first 8 postoperative days. The secondary objectives are to compare both arms with respect to cardiac complications within 48 h, renal and pulmonary complications within 21 days and mortality at 60 days. To assess the efficacy of IPC with respect to pulmonary and renal morbidity, a cox model for competing risks will be used. Assuming that the event occurs among 36% of the patients when no IPC is performed, the allocation of 55 patients to each arm should allow detecting a hazard ratio of at least 2.75 with a power of 80% when admitting 5% for an error of first kind. This means that 110 patients, enrolled in this multicenter study, may be randomised within 36 months of the first randomization. Randomization will be performed to allocate patients either to surgery with preconditioning before aortic cross clamping (Arm 1) or to surgery without preconditioning before aortic cross clamping (Arm 2). Randomization takes place during the intervention after intravenous injection of heparin, or after the start of femoral assistance. The procedure for IPC will be a supra-visceral thoracic aortic cross clamping for 5 min followed by an unclamping period of 5 min. This procedure will be repeated twice before starting thoracic aortic cross clamping needed to perform surgery.Conclusions: Our hypothesis is that ischemic preconditioning could reduce clinical morbidity and the incidence of lung damage associated with supra-visceral aortic clamping