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Eur J Cardiothorac Surg 1999;16:317-323
© 1999 Elsevier Science NL

Early and long-term results of surgery for aneurysms of the thoracic aorta in septuagenarians and octogenarians

^a Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka, Japan 565-8565
^b First Department of Surgery, Chiba University, Chiba, Japan
^c Department of Thoracic Surgery, Tokyo University, Tokyo, Japan

Corresponding author. Tel.: +81-6-8335012; fax: +81-6-8727486
e-mail: yokita{at}hsp.ncvc.go.jp

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion Appendix A References

 
Objective: The purpose of this study was to demonstrate early and long-term results of surgery for thoracic aortic aneurysm in patients over 70 years of age compared with those of patients under 70 years and to clarify the clinical problems peculiar to this subset of patients. Patients and Methods: Of 1157 patients who underwent surgery for thoracic aortic aneurysm from 1978 to December 1997, 261 who were 70 years or older were selected for analysis. Mean age at the time of surgery was 74.4±3.5 years. Aneurysms were atherosclerotic in 177 patients and aortic dissection in 84. Acute aortic dissection was found in 25 patients and ruptured aneurysm in 44. The control group consisted of 896 patients under 70 years. Preoperative complications such as AAA, peripheral arterial disease, emphysema, and old cerebral infraction were more common in the older group. Operative procedures consisted of replacement of the ascending aorta or hemiarch in 51 patients, total arch replacement in 75, distal arch replacement in 35, descending aorta replacement in 75, replacement of the thoracoabdominal aorta in 28, and extra-anatomical repair and others in 15. The technique of extracorporeal circulation was selective cerebral perfusion in 69 patients, deep hypothermic circulatory arrest in 90, femoro-femoral bypass in 39, left heart bypass in 12, and temporary aorto-arterial bypass in 30, and others in 21. Result: Early mortality was 21% (54 patients), which was greater than that of the control group (113 patients, 13%, P<0.01). The incidence of postoperative stroke, transient brain dysfunction, and respiratory problems was higher in the study group (P<0.01 in all). Mean duration in ICU among survivors was 9.3±20.2 days and that of the control group was 5.9±2.8 days (P<0.01). In a recent series (from 1991 to 1997) postoperative mortality improved to 15.6% (30/192 patients) in the study group however this result was still inferior to that of the control group (8.6%, 39/452, P=0.03) however mortality of emergency surgery during the same periods was still high (31%, 11/35 patients). Logistic regression analysis revealed that significant risk factors for postoperative hospital death were surgery before 1991, age over 70 years, preoperative cardiac problems, aneurysm rupture, postoperative stroke, low output syndrome, bleeding, and acute renal failure. Postoperative follow-up was obtained in 408 patients/year and the longest period was 10.2 years. Late deaths were documented in 31 patients. Five-year and 10-year survival were 61.2±5.7% and 31.3±16.4%, respectively. In the control group the 5-year and 10-year survival were 78.0±2.1% and 62.5±4.0%, respectively (P=0.03). However, survival of the early survivors in the study group was similar with that of the age-matched normal population. Aortic reoperation was performed in 13 patients. Freedom from aortic reoperation was 86.7±4.2% at 5 years and 80.5±7.1% at 10 years in the study group and 83.4±1.8% at 5 years and 64.1±13.3% at 10 years in the control group (P=0.27). Conclusion: Although recent advances have been achieved, early and long-term results of surgery for thoracic aortic aneurysm in patients older than 70 years were less satisfactory compared with those of patients under 70 years of age, especially in patients who required emergency surgery. Preoperative disorder of the vital organ systems was considered to be the main causative factor for high mortality, however, pertinent surgical strategies are necessary to improve the outcome of elderly patients.

Key Words: Thoracic aortic aneurysm • Elderly age • Stroke • Pulmonary emphysema • Emergency

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion Appendix A References

 
Advance in surgical technique and perioperative care in cardiovascular surgery have drastically reduced the mortality and morbidity in recent years. In parallel with this medical advancement, the major trend towards an advanced-age society has been accelerated among the developed countries in the last two decades. Coronary artery bypass, cardiac valve repair or replacement, and abdominal aortic aneurysm repair have been performed with an acceptable perioperative risk. Elective cardiovascular intervention in the elderly populations has not proven to be significantly more risky than in the younger populations [1–3]. However, repair of thoracic aortic aneurysm still bears a relatively higher risk compared with other cardiovascular procedures, especially when an emergent intervention is required [4,5]. The purpose of this study was to demonstrate early and long-term results of surgery for thoracic aortic aneurysm in patients over 70 years of age compared with those of patients under 70 years and to clarify the clinical problems peculiar to this subset of patients.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion Appendix A References

 
Of 1157 patients who underwent surgery for thoracic aortic aneurysm from 1978 to December 1997, 261 patients who were 70 years or older were selected for analysis. Mean age at the time of surgery was 74.4±3.5 years. The male to female ratio was 3.2 to 1. This cohort of patients amounted to 22.6% of our entire series of thoracic aortic surgery, however, the increased proportion of patients over 70 years has accelerated recently (Fig. 1). The control group consisted of 896 patients under 70 years.

View larger version (65K): [in this window] [in a new window]   Fig. 1. Annual numbers of patients with aneurysms of the thoracic aorta.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion Appendix A References

 
Regarding preoperative complications, a significantly higher incidence of preoperative hemodynamic derangement, abdominal aneurysms or peripheral arterial lesions, chronic obstructive lung disease, history of brain accident, and coexisting malignancy was found in the elderly group (Table 2).

Operative procedures consisted of replacement of the ascending aorta or hemiarch in 51 patients, total arch replacement in 75, distal arch replacement in 35, descending aorta replacement in 75, replacement of the thoracoabdominal aorta in 28, and extra-anatomical repair and others in 15. The incidence of procedures related to the aortic arch, specifically, procedures which required strategies for brain protection, was 61.7% of all procedures used in the elderly patients compared to less than half in the younger group. Applied extracorporeal circulation included selective cerebral perfusion in 69 patients, deep hypothermic circulatory arrest in 90, femoro-femoral bypass in 39, left heart bypass in 12, and temporary aorto-arterial bypass in 30, and others in 21. Early mortality, including hospital deaths, was 20.3% (53 patients) and greater than that of the control group (113 patients, 12.6%, P<0.01; Table 1). Major causes of early mortality were respiratory distress, postoperative stroke, mediastinal bleeding, and acute renal failure. Incidence of postoperative stroke, transient brain dysfunction, respiratory problems, and postoperative bleeding was higher in the study group (Table 3). Surprisingly, one-quarter of the elderly patients had a postoperative lung problem. One-quarter of the elderly were complicated with transient or permanent brain dysfunction. Stroke occurred in 10 percent of elderly patients. Mortality in each single organ system failure showed no difference, except for patients with stroke, in the elderly group compared with the control group (+). Patients with acute aortic dissection and hemiarch or total arch replacement had a higher mortality (Table 1). On the other hand, the results of the emergency operation showed no difference compared to that of elective surgery. The results of elective surgery for the elderly were worse than that of the younger populations. The elderly group was divided into two subgroups, 110 patients who were equal or older than 75 years and 151 patients younger than 75 years. The mortality of the elective surgery for patients who were 75 years old or more was 27.2% and tended to be higher than that of patients less than 75 years old (18.5%), but the difference was statistically insignificant. In a recent series (from 1991 to 1997), postoperative mortality improved to 15.6% (30/192 patients) in the study group, however, this result was still inferior to that of the control group (8.6%, 39/452, P=0.03). The mortality of emergency surgery in the same periods remained high (31%, 11/35 patients). Regarding emergency surgery, such as acute aortic dissection or aneurysm rupture, there has been virtually no progress since the beginning of our experience (early 1991, 26/75; recent 1992, 16/59; P=0.35). Stepwise logistic regression analysis (Table 5) demonstrated that perioperative predictive factors for hospital mortality of all patients with thoracic aortic aneurysm were earlier experience before 1991, age older than 70 years, preoperative cardiac lesions, and aneurysm rupture. Among 298 patients who underwent surgery for non-dissection aneurysm of the transverse aortic arch, independent risk factors for postoperative hospital deaths were earlier experience before 1991, preoperative chronic renal failure, aneurysm rupture, arch clamping, and use of the selective antegrade cerebral perfusion (Table 6). Chronological age was not proven to be a significant risk factor for early hospital death for the patients in this subset (Table 7). In 125 patients with thoracoabdominal aortic aneurysms, risk factors for early deaths were earlier experience before 1991, age older than 70 years, preoperative chronic renal failure, preoperative chronic obstructive lung disease, extensive aneurysm (Crawford type I and II), non-use of deep hypothermia, and aortic dissection (Table 7). In 121 patients who underwent emergency surgery for acute aortic dissection, perioperative risk factors for early deaths were earlier experience before 1991, age older than 70 years, acute type B dissection, presence of peripheral malperfusion syndrome, non-arch tear, and use of the selective antegrade cerebral perfusion (Table 8).

View larger version (22K): [in this window] [in a new window]   Fig. 2. Postoperative survival in patients with thoracic aortic aneurysm.

View larger version (18K): [in this window] [in a new window]   Fig. 3. Freedom from aortic reoperation in patients with thoracic aortic aneurysm.

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion Appendix A References

Usually, elderly patients tended to be referred late in the course of the disease. Forty-four (17%) of our elderly patients presented with a ruptured aneurysm, 25% required an emergency operation due to ruptured aneurysm or acute aortic dissection, and 37 (14%) patients were in shock. Girardi et al. [4] reported that seven out of 39 octogenarian cases of thoracoabdominal aortic aneurysm presented with ruptured aneurysms at the third referral center. Dean et al. [6] reported that more than 50% of their patients with ruptured abdominal aortic aneurysms had an unrecordable blood pressure. Gloziczki et al. [8] reported that 67% of their elderly patients with a ruptured abdominal aortic aneurysm were hypotensive, and 245 had a preoperative cardiac arrest. Mortality rates are consistently greater in hemodynamically compromised elderly patients; the patient whose aneurysm meets the criteria for repair should be meticulously investigated and undergo surgery on an elective basis.

The most grave complication after aortic surgery was newly-developed stroke. Our previous reports [5] demonstrated that postoperative stroke was a strong incremental risk factor for not only the early death, but also late death after aortic surgery. This phenomena was exaggerated in the elderly in this study. Every effort should be paid to prevent postoperative permanent brain complications. Details of the strategies or tactics for avoiding brain complications have been reported elsewhere [9–12]. Regarding brain protection, there have been two major trends since the dawn of aortic arch surgery. Deep hypothermic circulatory arrest with or without retrograde cerebral perfusion [9] and the antegrade selective cerebral perfusion technique [11,12] have advantages and shortcomings, respectively. However, as long as extracorporeal circulation was employed, the brain embolism might have occurred during cooling of the patients from the arterial cannulae before the circulatory arrest or antegrade cerebral perfusion was started [13–15]. Meticulous attention should focused upon selecting an arterial cannulation site, aortic clamping or manipulating the cerebral vessels.

Multivariate analysis revealed that the occurrence of preoperative cardiac lesions was a predictive factor for early death. These patients should have undergone repair before or should have had simultaneous repair of the cardiac defects at the time of aortic surgery. Moreover, patients with aneurysm certainly have a high incidence of insidious coronary artery disease. Dean et al. [6] found that in 23% of octogenarians undergoing abdominal aortic aneurysm repair, death was due to acute myocardial infarction. O'Hara et al. [7] reported that 31% of the same cohort of patients died of myocardial ischemia. These data suggest that a more aggressive search for ischemic heart disease was needed. Obviously the risk of correcting coronary artery disease with angioplasty or bypass grafting is less than the uniformly fatal outcome when incurring a perioperative myocardial infarction.

Postoperative pulmonary complications were the most prevalent problem seen in elderly patients undergoing thoracic aortic aneurysm repair and were proven to be a significant predictor for early mortality. Interestingly enough, the majority of those patients had preoperative chronic obstructive lung disease. Several studies [16,17] demonstrated that a close relationship existed between the incidence of the aortic aneurysms and pulmonary emphysema. Some investigators [16] have reported a reduced elastin content and increased elastase activity in patients with concomitant pulmonary emphysema and aortic aneurysm. Another report showed that chronic obstructive lung disease was a major contributing factor for rupture of the aortic aneurysms. Generally, the incidence and severity of the chronic obstructive lung disease increases with age. Elderly people commonly have a longstanding history of smoking and the resultant incidence of chronic obstructive lung disease is naturally high compared with younger generations. Procedures, which required left lung manipulation, such as surgery through left thoracotomy, had a significant risk of postoperative endobronchial bleeding or pneumonia [18]. We arbitrarily set the exclusion criteria for the thoracic aortic surgery as a pulmonary forced expiratory volume in 1 s below 800 ml. This was the minimum requirement for survival from our experience, otherwise patients could not expel the bronchial secretions and could not be weaned from the ventilator even with tracheotomy. Left recurrent nerve palsy and a large dose of blood transfusion were also major contributing factors underlying postoperative pulmonary complications.

Our exclusion criteria for the elective surgery, not emergent cases, for patients with thoracic aortic aneurysms are: (1) non-correctable severe heart disease, NYHA IV; (2) severe pulmonary emphysema with a forced expiratory volume less than 800 ml in 1 s; (3) severe liver cirrhosis with the indocyanine green excretion test over 40% at 15 min; (4) unconscious patients or recent cerebral bleeding within 1 month; (5) blood platelet count less than 50 000 mm³; (6) end stage metastatic malignant lesions; (7) methicillin-resistant Staphylococcus aureus carrier, or tuberculosis; (8) patients without family or social support. Patients with chronic renal failure under hemodialysis can undergo surgery. Patients should not be excluded from operations simply by chronological age.

	5. Conclusion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion Appendix A References

 
Although recent advance has been achieved, early- and long-term results of surgery for thoracic aortic aneurysm in patients older than 70 years were less satisfactory compared with those of patients under 70 years. This was emphasized in the elective operations. Preoperative disorder of the vital organ systems was considered to be the main causative factor for a high mortality and the long-term results after aortic surgery in the elderly were mainly affected by initial surgery. Pertinent surgical strategies and precise surgical skills, including a preoperative peer review of the patients and full application of intraoperative adjuncts to preserve end organ function, are necessary to improve the outcome of the elderly patients. However, we believe that age alone should not exclude a patient from undergoing repair of aneurysms of the thoracic aorta.

	Footnotes

 
Presented at the 12th Annual Meeting of the European Association for Cardio-thoracic Surgery, Brussels, Belgium, September 20–23, 1998.

	Appendix A

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion Appendix A References

 
Conference discussion
Dr E. Wolner (Vienna, Austria): I was a little bit surprised, perhaps, I have always seen this, that coronary artery disease is not a risk factor in the elderly group of patients because it's different here in Europe. Has this something to do with the general low incidence of coronary artery disease in your country?

Dr Okita: Yes, I think so. Only twelve percent of our elderly patients had significant coronary heart disease.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion Appendix A References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Yutaka Okita Kenji Minatoya Soichiro Kitamura Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Okita, Y. Articles by Takamoto, S. Search for Related Content PubMed PubMed Citation Articles by Okita, Y. Articles by Takamoto, S.