Hybrid repair versus conventional open repair for thoracic aortic arch aneurysms

Comprehensive review of hybrid aortic arch repair with focus on zone 0 TEVAR and our institutional experience

Even with increasing operator experience and a better understanding of the disease and the operation, intervention for aortic arch pathologies continues to struggle with relatively higher mortality, reintervention, and neurologic complications. The hybrid aortic arch repair was introduced to simplify the procedure and improve the outcome. With recent industry-driven advances, hybrid repairs are not only offered to poor surgical candidates but have become mainstream. This review discusses the evolution of hybrid repair, terminology pertinent to this technique, and results. In addition, we aim to provide a pervasive review of hybrid aortic arch repairs with reference to relevant literature for a detailed understanding. We have also discussed our institutional experience with hybrid repairs.

A single-center experience in the use of hybrid techniques for thoracic aortic pathology

The hybrid method of treating thoracic aortic pathology is devoid of the disadvantages of traditional open surgery and, at the same time, has a broader range of applications than the endovascular method. From 2014 to 2019, we researched 122 patients with thoracic aortic pathology treated with the hybrid method (open surgery with thoracic endovascular aortic repair (TEVAR) at the National M. Amosov Institute of Cardiovascular Surgery National Academy of Medical Science of Ukraine. In the general group, 34 patients had a descending aortic aneurysm without dissection or rupture; 71 patients had an aortic dissection (10 - acute, 9 - subacute, 52 - chronic), penetrating aortic ulcer (PAU) - 7, thoracoabdominal aneurysm (Crawford I-II) - 4, isolated aortic arch aneurysm - 2, residual enlargement aorta after previous ascending aortic grafting causing type A acute aortic dissection (TAAD) - 3, primary aortic thrombosis - 1. Patients admitted as elective surgery candidates had switched aortic arch vessels (debranching) in the first stage and TEVAR in the second stage. For emergencies (aortic rupture with uncontrolled bleeding, malperfusion syndrome), TEVAR operation was performed first. Long-term results of treatment after three and six months are satisfactory. The hybrid technique of aortic arch treatment using modern minimally invasive technologies can eliminate the pathology in the most dangerous segment of the main artery of the body, providing a reasonable level of hospital mortality - 4.2%, and a small number of neurological complications.

Late Retrograde Aortic Dissection after Hybrid Thoracic Endovascular Aortic Repair (TEVAR): A Case Report

Open total arch replacement is allied to high rates of mortality and morbidity; surgeons, therefore, tend to choose hybrid aortic arch repair as a less invasive operative procedure for the treatment of aortic arch aneurysms, especially in high-risk patients. However, studies on the early and late outcomes of patients undergoing hybrid aortic arch repair have revealed high rates of reintervention and reoperation compared with open total arch replacement. Here, we describe a male patient with late retrograde aortic dissection after hybrid thoracic endovascular aortic repair for aortic arch aneurysms. The patient returned 3 years after the procedure with signs of dyspnea on exertion and chest pain. Transthoracic echocardiography and computed tomography showed dissection of the ascending aorta, for which he underwent a redo Bentall procedure. The patient was weaned from cardiopulmonary bypass without any problem and discharged after 7 days.

Parallel grafts and physician modified endografts for endovascular repair of the aortic arch

Aortic arch aneurysms are a challenging clinical problem especially in high-risk patients. Open aortic arch replacement, even in the best of centers, carries significant risk of stroke or death in this high-risk population. Many high-risk patients are deemed inoperable and not offered repair. Branched and fenestrated thoracic endografts are currently undergoing clinical trials in the United States but are not yet commercially available. Many elderly and frail patients have significant brachiocephalic occlusive disease or anatomy excluding them for consideration for such clinical trials. These patients also present with acute aortic syndromes requiring urgent or emergent repair and are unable to participate in clinical trials due to the time required to have such devices available. Alternative endovascular therapies, including parallel stent grafts (including Chimneys, Snorkels and Periscopes) and physician modified thoracic endografts, have been used to treat such high-risk patients combined with commercially available thoracic endovascular aneurysm repair (TEVAR) devices. This paper aims to review the techniques and current reported outcomes from parallel stent grafts and physician modified devices used to treat high risk patients undergoing repair for aortic arch pathologies.

Hybrid repair versus conventional open repair for aortic arch dissection

BACKGROUND

A dissection of the aorta is a separation or tear of the intima from the media. This tear allows blood to flow not only through the original aortic flow channel (known as the true lumen), but also through a second channel between the intima and media (known as the false lumen). Aortic dissection is a life-threatening condition which can be rapidly fatal. There is debate on the optimal surgical approach for aortic arch dissection. People with ascending aortic dissection have poor rates of survival. Currently open surgical repair is regarded as the standard treatment for aortic arch dissection. We intend to review the role of hybrid and open repair in aortic arch dissection.

OBJECTIVES

To assess the effectiveness and safety of a hybrid technique of treatment over conventional open repair in the management of aortic arch dissection.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 8 February 2021. We also undertook reference checking for additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and clinical controlled trials (CCTs), which compared the effects of hybrid repair techniques versus open surgical repair of aortic arch dissection. Outcomes of interest were dissection-related mortality and all-cause mortality, neurological deficit, cardiac injury, respiratory compromise, renal ischaemia, false lumen thrombosis (defined by partial or complete thrombosis) and mesenteric ischaemia.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all records identified by the literature searches to identify those that met our inclusion criteria. We planned to undertake data collection and analysis in accordance with recommendations described in the Cochrane Handbook for Systematic Reviews of Interventions. We planned to assess the certainty of the evidence using GRADE.

MAIN RESULTS

We identified one ongoing study and two unpublished studies that met the inclusion criteria for the review. Due to a lack of study data, we could not compare the outcomes of hybrid repair to conventional open repair for aortic arch dissection.

AUTHORS' CONCLUSIONS

This review revealed one ongoing RCT and two unpublished RCTs evaluating hybrid versus conventional open repair for aortic arch surgery. Observational data suggest that hybrid repair for aortic arch dissection could potentially be favourable, but conclusions can not be drawn from these studies, which are highly selective, and are based on the clinical status of the patient, the presence of comorbidities and the skills of the operators. However, a conclusion about its definitive benefit over conventional open surgical repair cannot be made from this review without published RCTs or CCTs. Future RCTs or CCTs need to have adequate sample sizes and follow-up, and assess clinically-relevant outcomes, in order to determine the optimal treatment for people with aortic arch dissection. It must be noted that this may not be feasible, due to the reasons mentioned.

Hybrid repair versus conventional open repair for thoracic aortic arch aneurysms

BACKGROUND

Thoracic aortic arch aneurysms (TAAs) can be a life-threatening condition due to the potential risk of rupture. Treatment is recommended when the risk of rupture is greater than the risk of surgical complications. Depending on the cause, size and growth rate of the TAA, treatment may vary from close observation to emergency surgery. Aneurysms of the thoracic aorta can be managed by a number of surgical techniques. Open surgical repair (OSR) of aneurysms involves either partial or total replacement of the aorta, which is dependent on the extent of the diseased segment of the aorta. During OSR, the aneurysm is replaced with a synthetic graft. Hybrid repair (HR) involves a combination of open surgery with endovascular aortic stent graft placement. Hybrid repair requires varying degrees of invasiveness, depending on the number of supra-aortic branches that require debranching. The hybrid technique that combines supra-aortic vascular debranching with stent grafting of the aortic arch has been introduced as a therapeutic alternative. However, the short- and long-term outcomes of HR remain unclear, due to technical difficulties and complications as a result of the angulation of the aortic arch as well as handling of the arch during surgery.

OBJECTIVES

To assess the effectiveness and safety of HR versus conventional OSR for the treatment of TAAs.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 22 March 2021. We also searched references of relevant articles retrieved from the electronic search for additional citations.

SELECTION CRITERIA

We considered for inclusion in the review all published and unpublished randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing HR to OSR for TAAs.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles and abstracts obtained from the literature search to identify those that met the inclusion criteria. We retrieved the full text of studies deemed as potentially relevant by at least one review author. The same review authors screened the full-text articles independently for inclusion or exclusion.

MAIN RESULTS

No RCTs or CCTs met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

Due to the lack of RCTs or CCTs, we were unable to determine the safety and effectiveness of HR compared to OSR in people with TAAs, and we are unable to provide high-certainty evidence on the optimal surgical intervention for this cohort of patients. High-quality RCTs or CCTs are necessary, addressing the objective of this review.