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Biomedical subjects

Charles C Miller

Publications and source records attributed to Charles C Miller.

At least 37 records · Page 2Linked to original sources
PubMed2004

Cold visceral perfusion improves early survival in patients with acute renal failure after thoracoabdominal aortic aneurysm repair.

INTRODUCTION: Despite advances in organ protection during thoracoabdominal aortic aneurysm (TAAA) repair, acute renal failure (ARF) remains a significant clinical problem, associated with increased morbidity and mortality. We studied outcome of ARF after TAAA repair in patients who underwent either warm or cold visceral perfusion. METHOD: Between 1991 and 2001 657 TAAA repairs were performed, of which 359 (55%) had either warm or cold visceral perfusion. Twelve patients with renal failure who had undergone preoperative dialysis were excluded from the study. Of the remaining 347 patients, ARF developed in 81 (23%) after TAAA repair. Forty-four (54%) of the 81 patients with ARF received cold visceral perfusion, and 37 (46%) patients received warm visceral perfusion. ARF was defined as either an increase of 1 mg/dL in serum creatinine (SCr) concentration per day for 2 consecutive days or dialysis requirement. Patient records were reviewed through hospital discharge. RESULTS: Twenty six (32%) of the 81 patients in whom ARF developed died, 17 of 37 (46%) patients in the warm perfusion group versus 9 of 44 (21%) patients in the cold perfusion group (P <.02). Median onset of ARF was on postoperative day 1 in both groups. Twenty-six of 81 (32%) patients recovered renal function, 10 of 37 (27%) patients in the warm perfusion group versus 16 of 44 (36%) patients in the cold perfusion group. Preoperative SCr concentration was predictive of recovery of renal function (odds ratio, 4.5 per mg/dL increase; P <.03) in patients who received either warm or cold visceral perfusion. CONCLUSIONS: ARF after TAAA repair remains a significant clinical problem. Recovery of renal function occurred in approximately one third of patients. Preoperative SCr concentration was the only significant determinant of recovered renal function. While cold visceral perfusion did not alter renal recovery, it significantly reduced hospital mortality.

Acute Kidney Injury↗
PubMed2004

Staged repair of extensive aortic aneurysms: long-term experience with the elephant trunk technique.

OBJECTIVE: This paper reports our experience of a large series of elephant trunk patients accumulated over 12 years. SUMMARY BACKGROUND DATA: Extensive aneurysms of the ascending/arch and descending thoracic or thoracoabdominal aorta are significant surgical problems that have potential for great morbidity. We adopted a staged approach known as the elephant trunk procedure in 1991, and we have used it with some modifications since that time. METHODS: Between February 1991 and December 2003, we performed 1660 operations for ascending/arch or descending thoracic/thoracoabdominal aortic aneurysms. Of these, 321 operations were performed in 218 patients for extensive aneurysms with the elephant trunk technique. We performed 218 ascending/arch repairs and 103 descending thoracic or thoracoabdominal aortic replacements. RESULTS: In 218 ascending/arch repairs, strokes occurred in 3 of 218 (2.7%) patients, with 1 of 187 (0.5%) in the retrograde cerebral perfusion group and 2 of 31 (6.5%) in the no-retrograde cerebral perfusion group (odds ratio 0.08, P < 0.009). Thirty-day mortality for this group was 19 of 218 (8.7%). Among 199 recovering patients after stage 1 repair, 4 of 199 (2%) died during the 30-day to 6-week interval between stages. After stage 2 repair, 0 of 103 patients experienced immediate neurologic deficit, and 10 of 103 (9.7%) died within 30 days of surgery. Actuarial survival after completed stage 2 was 71% at 5 years. CONCLUSION: Despite extreme underlying disease, long-term survival is excellent in patients with extensive aneurysms when both stages of repair are completed. To prevent rupture, the second stage should be completed as soon as the patient's condition permits, preferably within 6 weeks.

Actuarial Analysis↗
PubMed2003

Brief intervention by surgeons can influence students toward a career in surgery.

BACKGROUND: General surgery training programs are experiencing an alarming decrease in applicants. The purpose of the current study was to determine whether exposing students to surgery through a brief intervention early in their medical education could influence perceptions toward surgery as a career choice. METHODS: First-year medical students were asked to rank 19 items coded on a Likert-type scale from 1 (not important) to 8 (very important) regarding their beliefs about surgery as a career both before and after a brief 1-h intervention with a panel of surgeons. Each panelist spoke about his or her professional and personal lives, followed by a question and answer period. Survey data were analyzed by Wilcoxon sign-rank and Spearman rank correlation. RESULTS: Of 210 first year students, 121 (58%) students voluntarily attended and completed the presurvey and 94 (45%) the post, of which 82 were matched responses. Preintervention responses revealed that career opportunities, intellectual challenge, and the ability to obtain a residency position were positively correlated with surgery (P < 0.007) whereas length of training, lifestyle during residency, lifestyle after training, and work hours during residency were negatively correlated (P < 0.01). The following factors were significantly influenced by the intervention: academic opportunities, patient relationships, prestige, and gender distribution became more important whereas concern about debt and length of training became less important. CONCLUSIONS: Positive encounters with surgeons can favorably influence the perceptions of first-year medical students toward a career in surgery. In addition to addressing lifestyle issues, surgeons can and must make a concerted effort to interact with medical students early in their education and foster their interest throughout their career.

Attitude↗
PubMed2003

Surgical outcome in 85 patients with primary cardiac tumors.

BACKGROUND: We present a large, single institution experience with adult cardiac tumors and address factors affecting outcome. METHODS: A retrospective review was made of all patients who underwent surgery for primary cardiac tumors from April 1975 through August 2002. RESULTS: Eighty-five patients (33 male and 52 female) with a mean age of 54 years were identified with follow-up available for 80 (94%) patients. There were 68 (80%) benign tumors and 17 (20%) malignant tumors. Three tumors recurred and were resected giving a total of 88 surgeries. All benign tumors were grossly resected and the extent of resection for malignant disease ranged from 14 (78%) gross resections and 3 (17%) debulkings to 1 (5%) biopsy. There were 4 (5%) early hospital deaths. Median survival was 9.6 months and 322 months for patients with malignant and benign diseases, respectively. Significant predictors of long-term mortality were malignant disease (P <0.0001) and New York Heart Association class (P <0.03). CONCLUSIONS: Surgical resection provides excellent outcome in patients with benign cardiac tumors. Malignant tumors continue to pose a challenge with good local tumor control but limited survival owing to metastatic disease.

Adolescent↗
PubMed2003

Estimating group mortality and paraplegia rates after thoracoabdominal aortic aneurysm repair.

BACKGROUND: Most clinical studies regarding thoracoabdominal aortic aneurysm (TAAA) surgery are retrospective comparisons involving heterogeneous groups of patients. Risk models that evaluate susceptibility bias enhance interpretation of these intergroup comparisons. The purpose of this analysis was to derive group risk models for mortality and paraplegia after TAAA repair. METHODS: Data regarding 1,220 consecutive patients undergoing TAAA repair were analyzed via multiple logistic regression with stepwise model selection. Categorical preoperative risk factors that predicted 30-day mortality and paraplegia were used to develop risk models. RESULTS: Fifty-eight patients (4.8%) died within 30 days and 56 patients (4.6%) developed paraplegia or paraparesis. Predictors of mortality were rupture, renal insufficiency, symptomatic aneurysms, and Crawford extent II repairs. Extent of repair and acute presentation were predictors of paraplegia. The derived risk models estimated mortality and paraplegia rates that correlated well with actual frequencies reported in other contemporary series (regression slopes = 0.87 and 1.06, respectively). CONCLUSIONS: The derived risk models accurately estimate paraplegia and mortality rates in groups of patients. Prospective model validation will be required to confirm their accuracy.

Adolescent↗
PubMed2003

Determination of cerebral blood flow dynamics during retrograde cerebral perfusion using power M-mode transcranial Doppler.

BACKGROUND: Retrograde cerebral perfusion (RCP) during profound hypothermic circulatory arrest has been used as an adjunct for cerebral protection for repairs of the ascending and transverse aortic arch. Transcranial Doppler ultrasound has been used to monitor cerebral blood flow during RCP with varying success. The purpose of this study was to characterize cerebral blood flow dynamics during RCP using a new mode of monitoring known as transcranial power motion-mode (M-mode) Doppler ultrasound. METHODS: Data on pump-flow characteristics and patient outcomes were collected prospectively for patients undergoing ascending and transverse aortic arch repair. Retrograde cerebral perfusion during profound hypothermic circulatory arrest was used for all operations. Intraoperative cerebral blood flow dynamics were monitored and recorded using transcranial power M-mode Doppler ultrasound. RESULTS: Between August 2001 and March 2002, we used transcranial power M-mode Doppler ultrasound monitoring for 40 ascending and transverse aortic arch repairs during RCP. Mean RCP time was 32.2 +/- 13.8 minutes. Mean RCP pump flow and RCP peak pressure for identification of cerebral blood flow were 0.66 +/- 0.11 L/min and 31.8 +/- 9.7 mm Hg, respectively. Retrograde cerebral blood flow during RCP was detected in 97.5% of cases (39 of 40 patients) with a mean transcranial power M-mode Doppler ultrasound flow velocity of 15.5 +/- 12.3 cm/s. In the study group, 30-day mortality was 10.0% (4 of 40 patients). The incidence of stroke was 7.6% (3 of 40 patients); the incidence of temporary neurologic deficit was 35.0% (14 of 40 patients). CONCLUSIONS: Transcranial power M-mode Doppler ultrasound consistently demonstrated retrograde middle cerebral artery blood flow during RCP. Transcranial power M-mode Doppler ultrasound can provide optimal RCP with individualized settings of pump flow.

Adult↗
PubMed2003

Preoperative and operative predictors of delayed neurologic deficit following repair of thoracoabdominal aortic aneurysm.

PURPOSE: Delayed neurologic deficit has been recognized in recent years as a source of morbidity following thoracic and thoracoabdominal aortic repair. We wanted to find risk factors specifically significant for delayed neurologic deficit. In this initial study we looked at preoperative and operative risk factors. METHODS: We performed 854 thoracoabdominal aortic repairs between February 1991 and May 2001. For this study we excluded 26 patients who died before postoperative neurologic status could be evaluated and 38 who had immediate neurologic deficit on initial postoperative evaluation, leaving 790 consecutive patients. We evaluated a wide range of demographic, preoperative physiological and intraoperative data, using univariate and multivariable statistical analyses. RESULTS: Twenty-one of 790 (2.7%) patients had delayed neurologic deficit. Significant univariate predictors included preoperative renal dysfunction (odds ratio 5.9; P <.006), acute dissection (odds ratio 3.9; P <.05), extent II thoracoabdominal aorta (odds ratio 3.0; P <.03), and use of adjuncts (cerebrospinal fluid drainage and distal aortic perfusion; odds ratio 7.7; P <.03). The use of the adjuncts dropped from the multivariable model but all other factors remained. No other significant risk factors were identified. Twelve of 21 (57%) patients recovered neurologic function with optimization of blood pressure and cerebrospinal fluid drainage. CONCLUSION: Preoperative renal dysfunction, acute dissection, and extent II thoracoabdominal aorta are significant predictors of delayed neurologic deficit. Previous studies have demonstrated that the use of adjuncts protects against immediate neurologic deficit. The findings of this study are consistent with the hypothesis that adjuncts reduce ischemic insult enough to prevent immediate neurologic deficit but that a period of increased spinal cord vulnerability persists several days postoperatively.

Adolescent↗
PubMed2003

Cardiac arrest survival as a function of ambulance deployment strategy in a large urban emergency medical services system.

INTRODUCTION: This study examines the effect of paramedic deployment strategy on witnessed ventricular fibrillation (VF) cardiac arrest outcomes. Our null hypothesis was that there is no difference in survival between an EMS system using targeted response (TR) and one using a uniform or all advanced life support (ALS) response (UR) model. We define targeted response as a system where paramedics are sent to critical incidents while ambulances staffed with basic EMTs are sent to less critical incidents. A secondary outcome measure was paramedic skill proficiency between the systems. METHODS: We conducted a retrospective review of all 1997 VF arrests in a large urban EMS system. The majority of the city is a busy, urban area that uses TR. Outlying areas of the city are suburban and are served by a UR model. All areas have first responders equipped with automated external defibrillators. Outcomes are compared using Utstein criteria. RESULTS: Patient populations were well matched. There were 181 patients in the TR group and 24 in the UR group. Units in the TR area were able to demonstrate shorter response and time to defibrillation intervals than in the UR area. Rates for return of spontaneous circulation (ROSC), admission to the ward/intensive care unit (ICU), survival to discharge and survival to 1 year were all better in the cohort of patients cared for in the TR area than those in the UR area. Rates for successful intubation and IV initiation were also better in the TR areas than in the UR areas. CONCLUSION: This study shows improved outcomes for a subset of patients with cardiac arrest when they are cared for in an area that uses TR compared to an area that uses a UR EMS system.

Advanced Cardiac Life Support↗
PubMed2003

Analysis of short-term multivariate competing risks data following thoracic and thoracoabdominal aortic repair.

OBJECTIVE: Estimating the overall successfulness of a treatment can be difficult when success is defined by freedom from multiple endpoints that are each subject to competing risks. We describe a method for modeling short-term competing outcomes. METHODS: We used polytomous categorical variable modeling to describe the 30-day onset of renal failure, neurologic deficit, stroke or death (events) following repair of 841 thoracoabdominal aortic aneurysms. This was to determine whether common risk factors had a multivariate association with these outcomes, and whether predictor variables might be positively associated with some outcomes and negatively associated with others. The goal was to determine whether a single aggregate-endpoint logistic model could accurately predict the probability of good outcome 30 days following surgery. RESULTS: When more than one event occurred in a single patient, the first (or most severe simultaneous) event was used for censoring. Five hundred and ninety-three out of 841 (70.5%) patients had no postoperative events. The most common event was renal failure. We detected five predictors that were significant for at least one of the four outcomes. These were age, poor preoperative renal function (RENAL), acute dissection, extent II aneurysm, and use of cerebrospinal fluid drainage and distal aortic perfusion (ADJUNCT). Only RENAL was significant for all outcomes. ADJUNCT was highly significant only for neurologic deficit in the polytomous analysis and dropped out of the aggregate-endpoint multiple logistic model. CONCLUSION: Polytomous-outcome multivariate categorical modeling can detect effects missed by aggregate models, and is a valuable and statistically powerful method for evaluating risk factor effects on multiple competing endpoints.

Adolescent↗
PubMed2003

Cardiac function predicts mortality following thoracoabdominal and descending thoracic aortic aneurysm repair.

OBJECTIVE: Previous studies have identified age, renal failure and aneurysm extent as predictors of mortality following thoracoabdominal and descending thoracic aortic aneurysm (TAA) repair. We studied the impact of coronary artery disease (CAD) and cardiac function on 30-day mortality following TAA repair. METHODS: Between February 1991 and May 2001, we performed 854 TAA repairs. Two hundred ninety-one patients (34%) had a history of coronary artery disease. One hundred forty-one/291 (49%) had undergone coronary artery bypass surgery (CAB) prior to TAA repair. We conducted multivariable analyses of known risk factors along with the left ventricular ejection fraction (EF) and prior CAB to determine the adjusted effect of CAD on outcome. RESULTS: Mortality in patients with CAD was 54/291 (18%) compared to 75/563 (13%) without CAD (P<0.05). In patients who had prior CAB, mortality was 31/141 (22%) compared to 98/713 (14%) patients without prior CAB, (P<0.02). In multivariable analysis, the effects of CAD and CAB on mortality were eliminated by consideration of a low EF (defined as less than 50%). CONCLUSION: Impaired left ventricular function appears to be the strongest cardiac predictor of mortality for TAA repair, independent of the presence of coronary artery disease or coronary artery bypass revascularization.

Adolescent↗
PubMed2003

Postoperative risk factors for delayed neurologic deficit after thoracic and thoracoabdominal aortic aneurysm repair: a case-control study.

OBJECTIVE: Delayed neurologic deficit after thoracoabdominal or thoracic aortic repair is an unusual complication. We previously examined the preoperative risk factors associated with immediate neurologic deficit to consider their relationship to delayed neurologic deficit. In the current study we wanted to determine whether postoperative events influence the likelihood of delayed neurologic deficit, independent of preoperative risk factors. METHODS: We studied postoperative hemodynamics and cerebrospinal fluid (CSF) drain function in patients who had delayed neurologic deficit (cases) and those who did not (controls). Our database contains data for 854 patients with descending thoracic and thoracoabdominal aortic aneurysm. Cases and controls were identified with a random number generator to select controls in an approximate 4:1 ratio. We identified 18 cases and 67 controls. Further data were obtained from medical records. RESULTS: We found no differences between the groups with regard to oxygen transport abnormalities, eg, pneumothorax, repeat intubation, cardiac arrest, atrial or ventricular dysrhythmia, or dialysis. Significant differences between the groups were present for CSF drain complications (eg, kinks, blood in CSF): 6 of 18 (33%) in the case group versus 3 of 67 (4.5%) in the control group (P <.003). Wide fluctuation in mean arterial pressure (MAP) was significant (P <.02), mainly because of very low MAP in the cases (P <.006). When odds ratio was adjusted for preoperative risk factors of extent II thoracoabdominal aortic aneurysm, acute aortic dissection, and chronic aortic dissection, MAP less than 60 mm Hg and CSF drain complications produced the highest odds of delayed neurologic deficit. CONCLUSION: No single risk factor explained the onset of delayed deficit. Rather, a combination of factors, especially lowest MAP and drain complications, produced the highest odds of deficit. Vigilant optimization of hemodynamics and immediate correction of CSF drain malfunction may prevent development of delayed neurologic deficit.

Aged↗
PubMed2003

Distal aortic perfusion and cerebrospinal fluid drainage for thoracoabdominal and descending thoracic aortic repair: ten years of organ protection.

OBJECTIVE: To report the long-term results of our experience using cerebrospinal fluid drainage and distal aortic perfusion in descending thoracic and thoracoabdominal aortic repair. SUMMARY BACKGROUND DATA: Repair of thoracoabdominal and thoracic aortic aneurysm by the traditional clamp-and-go technique results in a massive ischemic insult to several major organ systems. Ten years ago, we began to use distal aortic perfusion and cerebrospinal fluid drainage (adjunct) to reduce end-organ ischemia. METHODS: Between January 1991 and February 2003, we performed 1004 thoracoabdominal or descending thoracic repairs. Adjunct was used in 741 (74%) of 1004. Multivariable data were analyzed by Cox regression. Number needed to treat was calculated as the reciprocal of the risk difference. RESULTS: Immediate neurologic deficit was 18 (2.4%) of 741 with adjunct and 18 (6.8%) of 263 without (P < 0.0009). In high-risk extent II aneurysms, the numbers were 11 (6.6%) of 167 with adjunct, and 11 (29%) of 38 without. Long-term survival was improved with adjunct (P < 0.002). The long-term survival results persisted after adjustment for age, extent II aneurysm, and preoperative renal function. CONCLUSION: Use of adjunct over a long period of time has produced favorable results; approximately 1 neurologic deficit saved for every 20 uses of adjunct overall. In extent II aneurysms, where the effect is greatest, this increases to 1 saved per 5 uses. Adjunct is also associated with long-term survival, which is consistent with mitigation of ischemic end-organ injury. These long-term results indicate that cerebrospinal fluid drainage and distal aortic perfusion are safe and effective adjunct for reducing morbidity and mortality following thoracic and thoracoabdominal aortic repair.

Actuarial Analysis↗
PubMed2003

Both primary and secondary abdominal compartment syndrome can be predicted early and are harbingers of multiple organ failure.

BACKGROUND: Primary abdominal compartment syndrome (ACS) is a known complication of damage control. Recently secondary ACS has been reported in patients without abdominal injury who require aggressive resuscitation. The purpose of this study was to compare the epidemiology of primary and secondary ACS and develop early prediction models in a high-risk cohort who were treated in a similar fashion. METHODS: Major torso trauma patients underwent standardized resuscitation and had prospective data collected including occurrence of ACS, demographics, ISS, urinary bladder pressure, gastric tonometry (GAP(CO2) = gastric regional CO(2) minus end tidal CO(2)), laboratory, respiratory, and hemodynamic data. With primary and secondary ACS as endpoints, variables were tested by uni- and multivariate logistic analysis (MLA). RESULTS: From 188 study patients during the 44-month period, 26 (14%) developed ACS-11 (6%) were primary ACS and 15 (8%) secondary ACS. Primary and secondary ACS had similar demographics, shock, and injury severity. Significant univariate differences included: time to decompression from ICU admit (600 +/- 112 vs. 360 +/- 48 min), Emergency Department (ED) crystalloid (4 +/- 1 vs. 7 +/- 1 L), preICU crystalloid (8 +/- 1 vs. 12 +/- 1L), ED blood administration (2 +/- 1 vs. 6 +/- 1 U), GAP(CO2) (24 +/- 3 vs. 36 +/- 3 mmHg), requiring pelvic embolization (9 vs. 47%), and emergency operation (82% vs. 40%). Early predictors identified by MLA of primary ACS included hemoglobin concentration, GAP(CO2), temperature, and base deficit; and for secondary ACS they included crystalloid, urinary output, and GAP(CO2). The areas under the receiver-operator characteristic curves calculated upon ICU admission are primary= 0.977 and secondary= 0.983. Primary and secondary ACS patients had similar poor outcomes compared with nonACS patients including ventilator days (primary= 13 +/- 3 vs. secondary= 14 +/- 3 vs. nonACS = 8 +/- 2), multiple organ failure (55% vs. 53% vs. 12%), and mortality (64% vs. 53% vs. 17%). CONCLUSION: Primary and secondary ACS have similar demographics, injury severity, time to decompression from hospital admit, and bad outcome. 2 degrees ACS is an earlier ICU event preceded by more crystalloid administration. With appropriate monitoring both could be accurately predicted upon ICU admission.

Abdomen↗
PubMed2002

Age at acquisition of Helicobacter pylori infection: a follow-up study from infancy to adulthood.

BACKGROUND: Helicobacter pylori infection is common worldwide, but the time of acquisition is unclear. We investigated this issue in a cohort of children selected retrospectively from a population followed up for 21 years. METHODS: We monitored 224 children (99 black, 125 white; 110 male, 114 female) from 1975-76 (ages 1-3 years) to 1995-96. H pylori status was assessed by presence of serum IgG antibodies. FINDINGS: 18 (8.0%) children at age 1-3 years had H pylori antibodies (13% black vs 4% white children, p=0.008). By age 18-23 years, the prevalence of the infection was 24.5% (43% black vs 8% white participants, p< 0.0001). Of the 206 children not infected at baseline, 40 (19%) became infected by age 21-23. The crude incidence rate per year was 1.4% for the whole cohort, ranging from 2.1% at 4-5 years and 1.5% at age 7-9 years to 0.3% at 21-23 years. The seroconversion rate was higher among black than among white children (relative risk 3.3, 95% CI 1.8-6.2, p=0.001). The median age for seroconversion was 7.5 years for both races. Nine of the 58 seropositive children cleared the infection during follow-up. The rate of seroreversion per year was 1.1%; it was highest among children at age 4-5 years (2.2% vs 0.2% at ages 18-19). INTERPRETATION: Most newly acquired H pylori infections happened before age 10 years. Treatment and preventive strategies should be aimed at children in this age-group.

Adult↗
PubMed2002

Replacement of the ascending and transverse aortic arch: determinants of long-term survival.

BACKGROUND: Although little has been published on the natural history of aneurysms of the ascending aorta and aortic arch, long-term prognosis of untreated aneurysms is generally poor. We reviewed our 10-year experience in the repair of the ascending aorta and aortic arch to evaluate long-term outcome. METHODS: Between January 1991 and May 2001, we repaired 423 aneurysms of the ascending aorta or aortic arch using profound hypothermic circulatory arrest. Median age was 65 years. Retrograde cerebral perfusion (RCP) was used in 357 cases. Mean pump and RCP times were 139 and 33.9 minutes, respectively. Survival was ascertained by direct patient contact or by searching the social security death index. Survival was analyzed by Kaplan-Meier stratified analysis and by multivariate Cox regression. RESULTS: Overall actuarial survival was 72% at 5 years and 71% at 10 years after surgery. Univariate analysis identified increasing age (p < 0.0001), chronic obstructive pulmonary disease (p < 0.014), concurrent unoperated aneurysm (p < 0.005), arch involvement (p < 0.042), pump time (p < 0.0004), concurrent aortic valve replacement (p < 0.009), and postoperative renal failure (p < 0.0002) as factors that negatively influenced survival. Multivariate analysis identified increasing age (p < 0.0001) and pump time (p < 0.0001). RCP did not have a significant independent effect on the long-term survival. CONCLUSIONS: Our experience indicates that repair of the ascending aorta and aortic arch can be accomplished with good long-term survival.

Adolescent↗
PubMed2002

Staged repair of extensive aortic aneurysms.

BACKGROUND: We adopted a two-stage approach (elephant trunk procedure) in the repair of extensive aortic aneurysms in 1991, performing 241 procedures in 155 patients. METHODS: Reversed elephant trunk (graft replacement of the descending thoracic aorta followed by ascending/arch replacement) was performed in 18 patients. All other patients underwent conventional staged repair. The first stage was performed in 137 patients, with 86 patients returning for the second stage. RESULTS: First stage 30-day mortality was 9.5% (13 of 137). There was no second stage immediate neurologic deficit. Second stage mortality was 7.0% (6 of 86). During the interval of 31 days to 6 weeks after stage one, mortality was 10 of 124 (8%). Seven of the 10 interval deaths (70%) were due to rupture of the untreated aortic segment. The mortality rate was 32.1% (18 of 56) in the group of patients who did not return for the second stage repair. CONCLUSIONS: Extensive aortic aneurysms can be repaired with acceptable morbidity and mortality using the elephant trunk technique. After stage one, prompt treatment of the remaining aneurysm is crucial to success.

Aortic Aneurysm, Abdominal↗
PubMed2002

The effect of aortic dissection on outcome in descending thoracic and thoracoabdominal aortic aneurysm repair.

It is estimated that 20% to 40% of the patients who survive the acute phase of aortic dissection will develop significant aneurysmal dilatation of the descending thoracic or thoracoabdominal aorta. Aortic dissection has long been considered a risk factor for mortality and neurologic deficit following surgical repair of the descending thoracic and/or thoracoabdominal aorta. In this article we review the surgical approach to patients with aortic dissection and thoracoabdominal aortic aneurysms and discuss the impact of adjuncts on survival and neurologic outcome.

Aortic Dissection↗