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62
was noted pre-
operatively, most
impaired in physical
and social functioning
Main ndings related to
HRQOL
Post-operatively, there
was a statistically
signicant increase in
role functioning,
bodily pain, vitality,
social functioning, role
functioning emotional,
together with increase
in the PCS and MCS
Post-operative MCS
was affected by
post-operative
neurological
complications as well
as baseline PCS and
MCS while PCS was
only affected by
baseline PCS
Mean NIH stroke scale
improved was
5.5±2.9 at
M. K. H. Tan et al.
presentation and
improved to 1.9±2.6
at discharge
Mean modied Rankin
score improved from
2.1±1.3 at discharge to
0.8±0.9 at 12months
after the surgery
HRQOL
instrument used
Follow-up
completion rate
Pre-op
HRQOL
98.6%
(%)
assessment Follow-up period
Yes 1year SF-36 Low level of HRQoL
Mean age
56.8±11.5years
75.6% male
National
Medical
Research Center
of the Ministry
of Health of the
Russian
Federation,
Russia
Mean National
Institutes of
Health (NIH)
stroke scale
100%
No 18±5months Rankin scale
Mean age of patients
was 69±9years, 60%
were male
Pre-operative
neurological symptoms
were hemiplegia in 9
and motor aphasia in 1.
Kanto Medical
Centre, Tokyo,
Japan
CT conrmed evidence
of cerebellar infarction
in six of these patients
Author, year of
Table 4.4 (continued)
Study intent and number of
patients Surgical centre Patient characteristics
Assess HRQoL before and
one year after prosthetics of
the aorta for chronic type I
dissection (n=82)
publication,
study period
and study type
Kamenskaya
etal. 2019
[30]
2014–2015
Retrospective
cohort
Impact on QoL of immediate
type A dissection repair in
patients with cerebral
malperfusion (n=10)
Hemiarch replacement was
performed in 9 and total arch
replacement in 1
Nakamura
etal. 2011
[31]
2007–2010
Retrospective
cohort
4 Thoracic Aortic Surgery
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63
Overall HRQoL of survivors following type A
dissection repair was found to be acceptable in
studies performed in the early half of the last
decade [27, 31]. For example, Campbell-Lloyd
etal. showed that in patients with cerebral malperfusion, signicant improvement in overall
function at long-term follow-up was seen [27].
This is supported in a more recent study by
Kamenskaya etal., which showed that in a cohort
of 82 patients with chronic type I dissection,
HRQoL scores were improved with postdissection repair [30], but this comparison is
limited by the elective nature of these operations.
Interestingly, two more recent studies on emergency operations for type A dissection by Adam
et al. (210 respondents) [26] and Endlich et al.
(120 patients undergoing various operations)
[28] both showed signicantly worse HRQoL
when compared to an adjusted population, with
Endlich et al. also showing decaying HRQoL
over time. Ghazy etal. also showed that, while
not statistically signicant, patients undergoing a
less aggressive procedure (ascending aorta
replacement only) showed better HRQoL in all
domains of the SF-36 [29]. This supports the
argument for a life-saving procedure approaching the entry tear only in the acute setting [32],
with further operations to manage the remaining
tear further down the line [33].
Thoracoabdominal Aortic
Aneurysm Repair
Thoracoabdominal aortic aneurysms (TAAs) represent a spectrum of complicated degenerative
aortic disease, which is typically characterised
using the Crawford classication system. While
the incidence at a population level is low (estimated at 10 new cases per 100,000 person-years
[34]), the potential for rupture if untreated is
high, at nearly 80% [35]. Treatment for these has
shifted preferentially towards endovascular
options (described in the next section) due to the
invasiveness of open surgery. Open surgery however still has a major role, and remains the gold
standard for TAAs, especially in the elective setting for complex type 1 and 2 disease. HRQoL
outcomes have been described in six studies [36–
41] (Table 4.5 adapted from Jarral et al. [4]),
which have all assessed HRQoL in patients
undergoing elective TAA repair for various
extents of TAA.
In one of the few studies to examine baseline
HRQoL, Coroneos etal. showed that there was no
change in HRQoL of patients at 6 and 12months
after elective open TAA repair in 80 patients.
Baseline HRQoL was found to be lower than that
of healthy controls prior to the operation [36].
Further studies by Crawford etal. [37], Di Luozzo
etal. [38] and Eide etal. [39] also showed that, in
contrast to the studies on proximal aortic surgery
discussed previously, patients undergoing
descending and TAA surgery have worse HRQoL
compared to that of a normal population. In two
studies by Ghanta etal. [40] and Zierer etal. [41],
this inferior HRQoL was found to be limited to
physical health, with mental and psychological
components of health maintained or improved as
compared to the normal population. This lower
physical HRQoL may be due to baseline patient
characteristics, with TAA patients usually having
great burden of comorbidities (e.g. peripheral vascular disease, COPD). An alternative explanation
could be due to abnormal ow patterns in the
descending aorta having a complex impact on
HRQoL, more so than the ow patterns in the
proximal aorta. While the impact of ow patterns
on HRQoL have yet to be studied, current studies
have shown predictors for impaired HRQoL postoperatively to include increasing age, female gender, peripheral vascular disease, reoperations and
post-operative neurological events.
Endovascular Interventions
ontheThoracic Aorta
As alluded to in the previous section, endovascular options are increasingly favoured in the management of aortic disease. Four studies in the
current literature have observed HRQoL outcomes in patients undergoing endovascular interventions [42–45], and the results from these
studies are found in Table 4.6 (adapted from
Jarral etal. [4]).
64
Main ndings related to
HRQOL
instrument used
Follow-up
completion rate
HRQOL
No change in HRQoL at 6
and 12months following
thoracoabdominal
aneurysm repair
Pre-operative HRQoL was
lower than that of healthy
controls
IIRS tool and
KAS scale
(%)
44% at 1year
Measured pre-op, at
6months and 1year
after surgery
Healthy individuals
recruited as control
group
functional capacity,
measured at a mean of
5years postoperatively,
occurred rarely in
survivors of TAA repair
SF-36 Permanent loss of
67%
follow-up from
surgery of
60±38.7months
HRQoL was signicantly
lower in TAA repair
patients compared to the
general population
Predictors of pre-operative
reduced QoL were female
gender, age >75 and
peripheral vascular disease
Predictive factors of
reduced QoL after surgery
were post-operative
M. K. H. Tan et al.
paraplegia/CVA and
re-operation
TAA extent (I to IV) nor
operative urgency
inuenced long-term
HRQoL
Pre-op
HRQOL
assessment Follow-up period
Yes, but
Not reported specically
Toronto and
Study intent and
number of patients Surgical centre Patient characteristics
Assessment of QoL
only in
56%
in group undergoing QoL
assessment
Hamilton,
Ontario, Canada
after elective open
thoraco-abdominal
aneurysm repair
(n=80)
No Measured at a mean
Mean age of 69.5years
Male sex 619%
Diabetes—6.7%
Hypertension—85.1%
Coronary artery
disease—98.5%
Urgent surgery—12.7%
Massachusetts
General
Hospital,
Boston, USA
QoL assessed in
134 survivors of
open TAA repair
and compared to
age-adjusted
reference
population
Author, year of
publication,
study period and
study type
Coroneos etal.
2009 [36]
1998–2006
Prospective
Table 4.5 Studies observing thoracoabdominal aortic aneurysm repair
cohort study
Crawford etal.
2008 [37]
1987–2005
Retrospective
cohort study
4 Thoracic Aortic Surgery
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Main ndings related to
HRQOL
slightly lower than the
matched US population in
all HRQoL domains—
these differences were not
signicant except in the
vitality domain
SF-36 scores were
generally poorer than that
of the healthy population
in both physical and
mental dimensions but
comparable in other
domains
Patients who had an
uncomplicated
postoperative course all
reported general health
status comparable with
their pre-operative status
Patients who had
According to disease-
specic questions,
complicated postoperative
course generally scored
lower in the physical
impotence and pain were
dimensions
(continued)
reported as major
long-term postoperative
problems
65
HRQOL
instrument used
Follow-up
completion rate
Pre-op
HRQOL
(%)
SF-36 Respondents scored
81%
1.1–7.1)
assessment Follow-up period
No 4.1years (range
Mean age at operation
75±4.1years, 51% male
Replacement of
descending thoracic aorta
in 23.7% and
Mount Sinai
School of
Medicine,
NewYork, USA
SF-36 and “A
Vascular
1.3–14.1) years
No 6.2 (range
thoracoabdominal aorta in
76.3%.
Mean age at follow-up
was 67.4years
University
Hospital of
85%
specic
questionnaire”
(44.4–78.3)
Median aneurysm
diameter 7cm
Crawford classication: 4
Trondheim,
Norway
had type 2, four had type
3 and three had type 4
One emergency
presentation (rupture)
Study intent and
number of patients Surgical centre Patient characteristics
Retrospective
review of QoL of 93
over patients over
the age of 70
undergoing open
repair of descending
aortic aneurysm or
TAAA
Assessment of
HRQoL in
long-term survivors
of TAAA repair
(n=13)
Author, year of
publication,
study period and
study type
Di Luozzo
etal. 2013 [38]
2002–2008
Retrospective
cohort
Eide etal. 2005
[39]
1983–2001
Retrospective
cohort
66
Main ndings related to
HRQOL
instrument used
Follow-up
completion rate
HRQOL
MCS than the general
population
(%)
58.5%
follow up was similar
between the groups, but
physical HRQoL was
84%
lower after
thoracoabdominal
aneurysm versus
ascending/descending
aortic aneurysms
Age did not impact
HRQoL, but older patients
had improved
psychological HRQoL
Multivariate analysis
identied two factors to be
M. K. H. Tan et al.
independent predictors of
impaired late functional
status at 12months:
NYHA III or IV and
COPD
Psychological HRQoL
scores were similar to
age-matched US
population but physical
scores were diminished
(continued)
Pre-op
HRQOL
assessment Follow-up period
No 6.0±2.5years SF-12v2 Poorer PCS but better
Mean age 43±12years
Baylor College
Study intent and
number of patients Surgical centre Patient characteristics
Assess HRQoL in
No 35±20months SF-36 Psychological HRQoL at
65% male
Concomitant aortic
dissection noted—type I
(n=27, 55%) and IIIb
(n=18, 37%)
Mean age was
of Medicine,
Houston, TX,
USA
patients with
Marfan’s syndrome
undergoing type II
Washington
TAA repair (n=49)
Quality of life
67±9years and 49%
were male
University
School of
Medicine, USA
assessment in
patients undergoing
elective thoracic
aortic replacement
(n=110)
Twenty-nine
patients (26%)
underwent
ascending, 33
(30%) descending
and 48 (44%) TAA
aneurysm
replacement
Table 4.5
Author, year of
publication,
study period and
study type
Ghanta etal.
2016 [40]
2004–2010
Retrospective
cohort
Zierer etal.
2006 [41]
1998–2003
Retrospective
cohort
4 Thoracic Aortic Surgery
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Main ndings related to
HRQOL
No signicant different
in HRQoL in all
domains at follow-up
when comparing open
and TEVAR techniques
lower baseline scores
than those with
pararenal aortic
aneurysms
PCS declined
6–8weeks after
F-BEVAR and failed
to return to baseline at
12months in the TAA
group
Major adverse events
were associated with
PCS decline at
6–8weeks but not at
67
(continued)
longer follow-up
HRQOL
instrument used
Follow-up
completion rate
Follow-up
Pre-op
HRQOL
Surgical
(%)
period
No 34±18months SF-36 and
assessment
Mean age was
University
centre Patient characteristics
61%
HADS
questionnaire
signicantly higher in
TEVAR patients
(69±10years vs.
62±15years) as was
Hospital
Bern,
Switzerland
proportion of patients
undergoing emergency
intervention
Average aneurysm
diameter signicantly
larger in open group
(6.8±1.6cm vs
65%
Yes 12months SF-36 TAAs patients had
5.6±1.6cm)
Overall cohort: mean age
74.8±7.0years, 70%
male
TAA cohort: mean age
73.8±6.8years, 70.6%
Mayo Clinic,
Rochester,
MN, USA
male
Analyse changes in HRQoL
for patients with pararenal
aortic aneurysms (n=57) and
TAAs (n=102) with
F-BEVAR and compare these
outcomes with those in the
Outcome and QoL assessment
after open surgical (n=70)
Study intent and number of
patients
Author, year of
publication, study
period and study
Table 4.6 Studies observing endovascular interventions on the thoracic aorta
type
and endovascular (n=52)
Dick etal. 2008
[42]
2001–2005
intervention on the
descending thoracic aorta
Post-hoc
analysis of
prospective
collected series
Kärkkäinen
etal. 2019 [43]
2013–2016
Prospective
EVAR 1 trial
cohort
68
Main ndings related to
HRQOL
In comparing patients
with occluded vs.
patent LSA, the PCS
and MCS of the SF-12
and the DASH scores
were comparable and
the incidence of left
arm ischemia is low
However, during
subgroup analysis, in
patients with traumatic
aortic injury, the PCS
was superior when the
LSA was patent
No signicant
difference in SF-12
physical health scores
between the two
groups
The covered LSA
group had signicantly
better mental health
score
M. K. H. Tan et al.
No difference in LSA
symptoms between the
two groups or in ability
to return to normal
activities
HRQOL
instrument used
Follow-up
completion rate
Follow-up
Pre-op
HRQOL
Surgical
(%)
period
assessment
centre Patient characteristics
63%
SF-12
No 4.1±3.7years DASH
Not reported specically
in group undergoing QoL
assessment
Medical
University
Innsbruck,
Austria
“LSA
questionnaire”
Not reported
No 3.35±1.9years SF-12
Mean age of
46.7±21.7years
(signicantly lower age in
LSA uncovered group)
University of
Texas
Medical
School, USA
(continued)
Author, year of
Table 4.6
Report on the incidence of
left arm ischemia, left arm
function and QoL after
TEVAR by stent grafting with
Study intent and number of
patients
Klocker etal.
type
2014 [44]
publication, study
period and study
and without coverage of the
1996–2014
Retrospective
cohort
LSA
A total of 138 patients
underwent TEVAR, of who
68 had degenerative
aneurysm, 38 traumatic aortic
injuries and 36 type B
dissection. 73 of these had
Evaluation of long-term
effects of LSA coverage
(n=32) vs. non-coverage
LSA coverage, of which 9
had LSA revascularization
(n=50) during TEVAR on
McBride etal.
2015 [45]
2005–2012
Retrospective
symptoms and return to
normal activity in traumatic
aortic injury patients
cohort
4 Thoracic Aortic Surgery
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69
Only one study compared HRQoL between
open and endovascular interventions, performing a post hoc analysis on a prospectively collected database including 152 patients
undergoing TEVAR or open operations. Dick
et al. showed that at a mean follow-up of
34months, post- operative HRQoL were similar
between groups, despite the TEVAR group having older patients, more emergency procedures,
and smaller aneurysms [42]. Kärkkäinen etal.
was a recent study which observed HRQoL
changes from baseline following fenestratedbranched EVAR in two groups of patients with
either pararenal aortic aneurysms or TAAs [43].
All patients showed a decline in their physical
HRQoL at six to eight weeks after intervention,
but no decline in mental HRQoL.Interestingly,
this decline persisted in the TAA group at
12 months, while that of the pararenal aneurysm group returned to baseline values. It is a
common misconception that TEVAR should be
associated with better HRQoL than open surgery, which may stem from extrapolation from
studies on abdominal aorta stenting [46].
Kärkkäinen etal. showed lower physical component scores as compared to those obtained
from the EVAR 1 trial [47], and this could be
due to the anatomical and biomechanical differences innately found in the thoracic aorta.
Higher shear stress, anchorage issues, reduced
mechanical stability, endoleaks and other stentrelated contributions may contribute to decline
in HRQoL, which may explain why scores
might have been comparable in the non-randomised study by Dick etal. [42].
Two studies examined the HRQoL following
TEVAR with or without coverage of the left subclavian artery, showing no difference between
groups for the physical component score of the
SF-36 [44, 45], although McBride et al. showed
signicantly better mental component scores in
patients who had coverage of the left subclavian
artery [45]. This supports arguments for selective
revascularisation based on the underlying knowledge of patients’ vertebrobasilar anatomy. Both
studies also used a disease-specic questionnaire
in their analysis, which was not seen in other
studies.
Aortic Surgery intheElderly
Age has been identied as a predictor of mortality
in some studies [48], but refuted in others [49]. It
remains a controversial subject, as advanced age
may be used as a preclusive criterion by referring
clinicians and surgeons for major aortic surgery. In
the current literature, ve available studies in the
literature considered HRQoL outcomes in elderly
patients [1, 50–53] (Table4.7 adapted from Jarral
etal. [4]). In general, most studies found HRQoL
after major aortic surgery to be generally comparable to a matched population [1, 51–53].
Kurazumi etal. for example looked at HRQoL in
47 patients greater than 80years of age and having
>6 cm arch aneurysms, showing that in the 20
patients that were operated on, HRQoL and 5-year
survival were both comparable to an age- and sexmatched population [51]. Of note, this held true
even in emergency surgery for type A aortic dissection. One study by Jussli-Melchers etal. compared 242 patients divided by age, showing that
patients ≥70 years old had similar physical
HRQoL between groups. Additionally, the mental
HRQoL of the elderly group was slightly higher,
but this was not statistically signicant [50]. While
ndings of these studies should be considered
together with their sample sizes and study quality,
this suggests that clinicians should be positive
about the long-term HRQoL outcomes in patients
over the age of 80 undergoing major aortic surgery. While elderly age has been shown in the
studies above to impair pre- operative HRQoL
[37], it is more likely that co-morbidities have a
greater role in diminishing post-operative HRQoL.
Neurological Outcomes
andCerebral Protection
Neurological complications are dreaded by
patients and clinicians (in particular paraplegia),
with potential impact on short- and long-term
consequences. Six studies were identied in the
current literature which focused on neurological
outcomes and methods of cerebral protection
methods in thoracic aortic interventions [54–59]
(Table4.8). In summary, prolonged DHCA peri-
70
HRQOL
instrument
used
Main ndings related to
HRQOL
between the groups
MCS score might be
slightly higher in the
Follow-up
completion
rate (%)
91%
elderly group but not
statistically signicant
between those in the
57.1%
surgical group and those in
the medical group
M. K. H. Tan et al.
Pre-op
HRQOL
assessment Follow-up period
No 1year SF-36 PCS score was similar
Younger group: mean
age 56±10years, 70.7%
male
Elderly group: mean age
University of
Schleswig-
Holstein,
Campus Kiel,
Study intent and number
of patients Surgical centre Patient characteristics
HRQoL compared
between patients
<70years old (n=164)
and patients ≥70years
No 31.7±26.1months SF-36 HRQoL was similar
76±4years, 48.7% male
Presentation with cardiac
tamponade higher in the
elderly group
Similar baseline patient
characteristics between
the two groups
Kiel, Germany
old (n=78) 1year after
surgery
Yamaguchi
University
School of
Medicine,
Quality of life
assessment in 47 patients
over the age of 80
referred with aortic arch
Japan
pathology who ideally
required surgery
(>6cm): 20 operated on
and 27 treated medically
(patient choice)
‘Frail’ individuals were
excluded
In the surgical cases:
conventional total arch
replacement in 15,
debranched TEVAR in 2
and chimney TEVAR in
3
Author, year of
Table 4.7 Studies observing aortic surgery in the elderly
publication,
study period and
study type
Jussli-Melchers
etal. 2017 [50]
2004–2014
Retrospective
cohort
Kurazumi etal.
2014 [51]
2003–2012
Retrospective
cohort
4 Thoracic Aortic Surgery
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functioning, role-physical,
social functioning and role
emotional) of HRQoL after
thoracic aortic surgery was
Main ndings related to
HRQOL
lower than when compared
to a matched normal
population, although this
seemed to affect younger
subgroups more
Prolonged ACP time
(>120min) was associated
with signicantly lower
generalized perception of
scores in the dimension of
role-physical in SF-36
Operative urgency, type of
operation and presence of
type A dissection did not
inuence QoL outcomes
independency and
(continued)
well-being, comparable to
an age-matched population
71
HRQOL
instrument
used
Follow-up
completion
rate (%)
Pre-op
HRQOL
assessment Follow-up period
SF-36 Some measures (physical
74%
13–167)
No 62months (range
Mean age
70.6±4.2years, 38.7%
were female.
39.6% of patients
presented with an aortic
dissection
Tohoku
University,
Japan
100%
No 44±38months RAND-36 HRQoL revealed a
Mean age was
78±3years, 52.5% were
male and 22.5% had
cardiogenic shock on
admission
University of
Verona, Italy
Clinical outcome and
QoL analysis in 40
patients aged 75 and
older undergoing type A
dissection repair
Surgical procedures
were: interposition graft
(85%), root replacement
(12.5%) and interposition
Investigation in to the
Study intent and number
Author, year of
publication,
study period and
QoL in elderly
of patients Surgical centre Patient characteristics
Oda etal. 2004
[52]
study type
(>65years) following
thoracic aortic surgery
(n=150)
Aortic root replacement
was performed in 5
1987–1999
Retrospective
cohort
(4.5%), interposition
graft in 23 (20.7%), total
arch replacement in 44
(39.7%), replacement of
the thoracic descending
aorta in 30 (27.0%) and
TAA repair in 9 (8.1%)
Santini etal.
2006 [53]
1990–2004
Retrospective
cohort
graft with AVR in 2.5%
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