Progress in the management of type I thoracoabdominal and descending thoracic aortic aneurysms

We reviewed our categorization of patients at high risk for neurologic comp lications in the repair of descending thoracic and thoracoabdominal aortic aneurysm in which we used cerebrospinal fluid drainage and distal aortic pe rfusion (adjuncts). A total of 409 patients were operated on by one surgeon for descending thoracic or thoracoabdominal aortic aneurysm between 1992 a nd 1997. Of these patients, 232 had total descending thoracic or type I tho racoabdominal aortic aneurysm, 131 (56%) of whom were operated on with adju ncts. These patients were compared to 101 nonadjunct patients for demograph ic variables, intraoperative variables, blood product consumption, and neur ologic status. In 131 consecutive patients with adjuncts, all but one awoke from anesthesia without neurologic deficit. In nonadjunct patients, howeve r, neurologic deficit occurred in 6 of 101 (6%) (p < 0.003). The adjunct gr oup had more preoperative renal insufficiency (p < 0.05), an established ri sk factor for neurologic deficit (odds ratio = 2.2 in published studies). A ll other risk factors for neurologic deficit occurred with comparable frequ ency in both groups. We conclude that the introduction of adjuncts has dram atically reduced the neurologic risk associated with type I thoracoabdomina l or total descending thoracic aortic repair. Previously considered high ri sk for neurologic complications, these aneurysms can now be reclassified as low risk in surgery accompanied by adjuncts. Future investigations will fo cus on type II thoracoabdominal aortic aneurysm as the major source of neur ologic morbidity.