Postoperative Complications Decrease Long-Term Survival After Thoracic Aneurysm Repair Despite Apparently Successful “Rescue” From Early Mortality
Authors: Benjamin O. Patterson, Kate Stenson, Matthew Grima, Jorg de Bruin, Nawaf Al-Subaie, Ian M. Loftus, Matt M. Thompson, Peter J. Holt
Journal: Circulation (2018)

endovascular surgery ◼ mortality ◼ outcomes E lective repair of thoracic aortic aneurysms is a prophylactic procedure performed when the risk of aneurysm rupture is judged to outweigh perioperative risk.It has been demonstrated that mortality because of any cause in the 5 years after repair in frail surgical candidates is high, despite the fact that perioperative mortality is relatively favorable and aortic-related death is reduced. 1,2atient selection, therefore, is vital if survival gains are to be achieved through elective repair of thoracic aneurysms.Preoperative factors are known to affect life expectancy after surgery, but the effect of perioperative complications on subsequent survival has not been reported.Patients undergoing elective thoracic aneurysm repair for thoracic aortic aneurysm from the updated MOTHER (Medtronic Thoracic Endovascular Registry) were studied, which comprises 7 clinical trials and 1 institutional series. 3Subjects with aneurysmal chronic aortic dissection were excluded.Perioperative complications were classified as neurological, cardiac, renal, respiratory, or access vessel-related.For all clinical trials, adverse events were reported via the trial data-collection process and were adjudicated by a review panel according to trial protocol.For the St George's Vascular Institute cohort, all adverse events were reviewed by 2 experienced clinicians and classified after discussion.The 30-day mortality rates associated with each were calculated, which represented the failure to rescue rate, and Kaplan-Meier analysis was performed to determine the effect of having each complication on long-term survival.The cumulative effect of multiple complications was studied, and a cutoff that split the group into those at high or low risk of all-cause mortality was established.Institutional Review Board approval was obtained separately for all constituent studies.Informed consent was given for all commercial registries but was not required for the institutional case series because it was determined to be a retrospective study by the Institutional Review Board.Of the 635 patients included in the study from the MOTHER registry, 38.5% had ≥1 complication, and 14.6% had >1.Mean follow-up was 3.7 years with a range of 0 to 10.4 years.Neurological complications occurred in 10.5% of patients, respiratory in 11.4%, cardiac in 8.5%, renal in 6.1%, and access complications in 21.7%.All classes of complications were associated with increased mortality within the first 30 days and during the 5-year follow-up period (log-rank P<0.001) in categories except access-related, which was P=0.012.Early mortality rates were 7.2%, 15.5%, 21.4%, and 25% for those with 1, 2, 3, and 4 complications, respectively.There was a sequential reduction in 5-year survival among patients experiencing cumulative complications (Figure).Those who had ≥2 complications had significantly worse late survival than others patients, with an estimated mean survival of 3.2 (95% confidence interval, 2.6-3.9)versus 7.2 (95% confidence interval, 6.6-6.8)years in those who did not (log-rank P<0.001).Survival was reduced even when patients dying ≤90 days of surgery are removed from the survival analysis.Cox's regression modeling demonstrated that renal (odds ratio, 2.1; 95% confidence interval, 1.5-3.0)