Open repair of thoracoabdominal aortic aneurysms under left heart bypass

BACKGROUND: Thoracoabdominal aortic aneurysm (TAAA) open surgical repair (OSR) is a highly complex procedure associated with significant mortality and morbidity. Despite advancements in surgical techniques and organ protection strategies, TAAA OSR remains a challenge. This study analyzes nearly 35 years of experience at a single center, with a focus on the evolution of surgical approaches and adjuncts, particularly the use of left heart bypass (LHBP) for organ perfusion maintenance. METHODS: This retrospective study was performed on all the patients who underwent elective TAAA OSR at our institution between 1989 and 2024. Patients were divided into two groups: Group 1 (1989-2009), where adjuncts were used selectively, and Group 2 (2010-2024), where a systematic multimodal approach was implemented. Preoperative, intraoperative, and postoperative data were analyzed to assess the impact of evolving surgical techniques, adjuncts, and patient outcomes. Key adjuncts included cerebrospinal fluid drainage (CSFD), motor and somatosensory evoked potentials (MEP&SSEP), LHBP, renal perfusion strategy, and rotational thromboelastometry. RESULTS: In total, 1211 patients underwent elective TAAA OSR, with 455 patients in Group 1 and 756 in Group 2. A modified surgical approach was employed in the two groups, with significant differences in terms of sites of aortic cross-clamping, techniques for vessel reconstruction, and approach in the management of intercostal artery. In addition, significant differences between the groups were observed for what concern the use of adjuncts. Regarding the outcomes, Group 2 demonstrated a significantly lower 30-day mortality rate (7.5% in Group 2 vs. 13.4% in Group 1; P=0.001), and a reduction in permanent spinal cord ischemia (SCI) (7.4% in Group 2 vs. 11.9% in Group 1; P=0.012). Additionally, Group 2 exhibited trends toward reduced respiratory failure and renal complications, but these differences were not statistically significant. CONCLUSIONS: This single-center experience highlights the evolution of TAAA OSR over 35 years, demonstrating a significant reduction in mortality and SCI with the use of a comprehensive, multimodal approach. Although there were improvements in postoperative complications, further advancements are needed in this complex field to optimize outcomes. The ongoing refinement of surgical techniques and adjuncts continues to play a crucial role in improving patient care.