The Association Between Operative Times and Outcomes in Complex Endovascular Repair of Thoracoabdominal Aortic Aneurysms

Endovascular aortic repairs of aneurysms involving the thoracoabdominal aorta (eTAAA) are becoming increasingly common. However, there are no commercially available grafts in the United States for these repairs, and as a result, experience and repair methods vary widely and data are limited. We therefore sought to explore the impact of operative time on perioperative outcomes following eTAAA. We studied all eTAAA repairs (Crawford types 1-3) from 2014 to 2021 in the Vascular Quality Improvement database, and categorized them into quartiles of total operating time. To account for variations in case complexity and intraoperative events, we performed a subanalysis stratifying each surgeon by their median operating time. Multilevel logistic regression was employed to compare perioperative outcomes. We identified 921 complex endovascular thoraco-abdominal aortic repairs. Operating times ranged from <204 minutes in quartile 1 (Q1), to >360 minutes in Q4. Patient demographics, procedural urgency, and aneurysm extent were similar across quartiles. However, repairs in the first quartile were more often staged procedures, with fewer target vessels incorporated, lower usage of spinal drains, and less often utilized parallel grafts or upper extremity access. High volume surgeons and high volume hospitals were more likely to have lower procedure times. In adjusted analysis, procedures in Q3 (270-360 minutes) were associated with double the odds of almost every major perioperative outcome compared to Q1, and Q4 was associated with 3- to 8-fold higher odds. This included mortality (Q3: odds ratio [OR], 1.3; 95% confidence interval [CI], 0.6-2.8; P = .5; Q4: OR, 4.2; 95% CI, 2.1-8.5; P < .001), thoracoabdominal life-altering events (a composite of perioperative death, stroke, permanent paralysis and dialysis) (Q3: OR, 2.2; 95% CI, 1.1-4.1; P = .02; Q4: OR, 8.0; 95% CI, 4.3-15.0; P < .001), spinal cord ischemia (Q3: OR, 2.4; 95% CI, 1.02-5.6; P = .045; Q4: OR, 5.2; 95% CI, 2.3-11.6; P < .001), and acute kidney injury (Q3: OR, 2.2; 95% CI, 1.2-4.0; P = .009; Q4: OR, 5.0; 95% CI, 2.8-8.9; P < .001). Similar trends were seen for rates of major adverse cardiac events, myocardial infarction, and need for dialysis (Table, Figure). Results were consistent when surgeons were analyzed by median procedure time, as surgeons who ranked in the fourth quartile were associated with higher odds of perioperative death, thoracoabdominal life-altering events, major adverse cardiac events, and acute kidney injury. In this study, longer operative time in eTAAA was associated with a higher risk of adverse perioperative outcomes. These results suggest that expeditious repairs, with a focus on avoiding prolonged renal/visceral, pelvic and leg ischemia, are important in achieving optimal results in these challenging repairs, and suggest that strategies such as staged repairs may improve outcomes by decreasing procedure times.TableOdds ratios for perioperative outcomes based on operating time.First quartile (<204 minutes)Second quartile (205-269 minutes)P valueThird quartile (270-360 minutes)P valueFourth quartile (>360 minutes)P valueMortalityRef0.6 [0.2-1.5J0.271.3 [0.6 -2.8]0.454.2 [2.1-8.5]<.001TALERef1.6 [0.8-3.110.22.2 [1.1-4.110.0218.0 [4.3-15.01<.001StrokeRef2.5 [0.4-14.610.321.6 [0.3 -9.7]0.613.6 [0.6-20.2[.15MIRef0.8 [0.2 – 2.9]0.773.7 [1.3 -10.3]0.0143.1 [1.1-8.9].032MACERef1.2 [0.6-2.3)0.581.9 [1.03 – 3.5]0.0384.8 [2.7-8.76]<.001AKIRef0.9 [0.5-1.810.762.2 [1.2 -4.0]0.0095.0 f2.8-8.91<.001SCIRef1.6 [0.6-3.9)0.312.4 [1.02 – 5.5]0.0455.2 [2.3-11.6]<.001Permanent SCIRef1.6 [0.5-5.8]0.452.6 [0.8-8.5]0.116.3 [2.0-19.6].001DialysisRef0.9 [0.2-3.9J0.932.2 [0.6 -7.8]0.215.8 [1.8-18.51.003AKI, Acute kidney injury; MACE, major adverse cardiac event; MI, myocardial infarction; SCI, spinal cord ischemia.Values are adjusted by total operating time. Open table in a new tab