Hybrid-procedures for the Treatment of Thoracoabdominal Aortic Aneurysms and Dissections

Results of the North American Complex Abdominal Aortic Debranching (NACAAD) Registry

BACKGROUND

Hybrid debranching repair of pararenal and thoracoabdominal aortic aneurysms was initially designed as a better alternative to standard open repair, addressing the limitations of endovascular repair involving the visceral aorta. We reviewed the collective outcomes of hybrid debranching repairs using extra-anatomic, open surgical debranching of the renal-mesenteric arteries, followed by endovascular aortic stenting.

METHODS

Data from patients who underwent hybrid repair in 14 North American institutions during 10 years were retrospectively reviewed. Society of Vascular Surgery scores were used to assess comorbidity risk. Early and late outcomes, including mortality, morbidity, reintervention, and patency were analyzed.

RESULTS

A total of 208 patients (118 male; mean age, 71±8 years old) were treated by hybrid repair with extraanatomic reconstruction of 657 renal and mesenteric arteries (mean 3.2 vessels/patient). Mean aneurysm diameter was 6.6±1.3 cm. Thoracoabdominal aortic aneurysms were identified in 163 (78%) patients and pararenal aneurysms in 45 (22%). A single-stage repair was performed in 92 (44%) patients. The iliac arteries were the most common source of inflow (n=132; 63%), and most (n=150; 72%) had 3 or more bypasses. There were 30 (14%) early deaths, ranging widely across sites (0%-21%). A Society of Vascular Surgery comorbidity score >15 was the primary predictor of early mortality (P<0.01), whereas mortality was 3% in a score ≤9. Early complications occurred in 140 (73%) patients and included respiratory complications in 45 patients (22%) and spinal cord ischemia in 22 (11%), of whom 10 (45%) fully recovered. At 5 years, survival was 61±5%, primary graft patency was 90±2%, and secondary patency was 93±2%. The most significant predictor of late mortality was renal insufficiency (P<0.0001).

CONCLUSIONS

Mortality after hybrid repair and visceral debranching is highly variable by center, but strongly affected by preoperative comorbidities and the centers' experience with the technique. With excellent graft patency at 5 years, the outcomes of hybrid repair done at centers of excellence and in carefully selected patients may be comparable (or better) than traditional open or even totally endovascular approaches. However, in patients already considered as high-risk for surgery, it may not offer better outcomes.

Hybrid Repair of Type B Aortic Dissection With Thoracoabdominal Aortic Aneurysmal Degeneration in the Setting of Marfan Syndrome

Aneurysmal degeneration of the thoracoabdominal aorta after aortic dissection is a well-documented sequela of Marfan syndrome (MFS). Hybrid technique (HT), an emerging treatment modality for complex aortic pathologies, decreases morbidity and mortality relative to open surgery. However, outcome data regarding HT in genetic aortopathies such as MFS is limited. We describe a case of a young male with hypertension and type B aortic dissection (AD) complicated by a symptomatic thoracoabdominal aortic aneurysm (TAAA). He underwent staged HT comprised of carotid-carotid transposition followed by zone 1 thoracic endovascular aortic repair and concurrent retrograde left subclavian stent graft placement. Genetic analysis was consistent with Marfan syndrome. Subsequent growth of his TAAA warranted open extent type IV TAAA repair with individual renovisceral and iliac bypasses. The patient recovered from the second surgery without further progression of disease or late complication.

[Thoracoabdominal aneurysms]

Endovascular treatment of thoracoabdominal aneurysms: what's new? Thoracoabdominal aneurysms (T-AAA) are aortic aneurysms that involve both the thoracic and abdominal segments of the aorta and its associated visceral branches. Although the first successful open repair was reported over 50 years ago, the risks of treatment remain considerable. As the first generations of devices available for endovascular aneurysm repair (EVAR) were relatively simple tubes or bifurcated grafts, initial attempts to extend the benefits of EVAR to patients with T-AAA lead to "hybrid solution". Good results with hybrid repairs have not been universal and the approach does not exploit all of the potential advantages of a "pure" endovascular approach (lesser surgical insult). This unmet need, together with rapid technological advances, has encouraged the development of custom-made endografts with fenestrations and/or branches (F-BEVAR) for extension into the visceral vessel ostia. F-BEVAR requires considerably more complex device design and planning than conventional EVAR. Deployment is more technically demanding and takes longer to complete. Thus, patient, aneurysm anatomy and surgical team selection is paramount. Favorable outcomes have been widely reported following T-AAA repair with F-BEVAR in expert centers; more complex aortic lesions such as T-AAA in the context of chronic dissection or arch aneurysms are thus now also offered endovascular repair with F-BEVAR.

[Staged approach for hybrid thoracoabdominal aortic replacement]

AIM

To generalize our experience of step-by-step hybrid thoracoabdominal aortic replacement.

MATERIAL AND METHODS

Twenty-three patients were enrolled who underwent staged hybrid treatment of thoracoabdominal aortic aneurysm. There were 5 (21.7%) women and 18 (78.3%) men aged 61.4±8.3 years (37-74 years). The first stage was proximal debranching, the second - distal (abdominal) procedure and the third - stenting of the thoracoabdominal aorta.

RESULTS

There were no any complications after proximal debranching and aortic stenting. Abdominal debranching was followed by lethal outcome in 3 (13.0%) patients and early postoperative occlusion of the prosthesis brunch in 3 out of 87 cases.

CONCLUSION

Staged approach for hybrid surgical treatment is optimal solution, especially in high risk patients. In our opinion no necessity for cardiopulmonary bypass is the main advantage of this technique.

Debranching aortic surgery

Conventional open surgery still remains as the gold standard of care for aortic arch and thoracoabdominal pathology. In centers of excellence, open repair of the arch has been performed with 5% immediate mortality and a low rate of complications; however overall mortality rates are around 15%, being up to 40% of all patients rejected for treatment due to their age or comorbidities. For thoracoabdominal aortic pathology, data reported from centers of excellence show immediate mortality rates from 5% to 19%, spinal cord ischemia from 2.7% to 13.2%, and renal failure needing dialysis from 4.6% to 5.6%. For these reasons, different alternatives that use endovascular techniques, including debranching procedures, have been developed. The reported results for hybrid debranching procedures are controversial and difficult to interpret because series are retrospective, heterogenic and including a small number of patients. Clearly, an important selection bias exists: debranching procedures are performed in elderly patients with more comorbidities and with thoracoabdominal aortic aneurysms that have more complex and extensive disease. Considering this fact, debranching procedures still remain a useful alternative: for aortic arch pathology debranching techniques can avoid or reduce the time of extracorporeal circulation (ECC) or cardiac arrest which may be beneficial in high-risk patients that otherwise would be rejected for treatment. And compared to pure endovascular techniques, they can be used in emergency cases with applicability in a wide range of anatomies. For thoracoabdominal aortic aneurysms, they are mainly useful when other lesser invasive endovascular options are not feasible due to anatomical limitations or when they are not available in cases where delaying the intervention is not an option.

Propositions for Refinement of the Hybrid Surgical Technique for Treatment of Thoraco-Abdominal Aortic Aneurysm

Traditional open repair of thoraco-abdominal aortic aneurysms Crawford type II-IV carries a high perioperative risk and mortality. The hybrid technique for combined surgical and endovascular treatment offers an interesting alternative with reduced risk of paraparesis and possibly a reduced mortality rate. Propositions for refinement of this approach are outlined based on a single centre experience.

Staged hybrid open and endovascular exclusion of a symptomatic thoracoabdominal aortic aneurysm in a high-risk patient

Thoracoabdominal aortic aneurysms have a higher prevalence in the elderly, who are often poor surgical candidates. These extensive aneurysms may be lethal if left untreated. Conventional open repair has proven to be a major task, involving cardiopulmonary bypass, aortic cross-clamping and expeditious repair of an inaccessible structure involving two body cavities. Endovascular repair has become a viable option to treat isolated descending thoracic aneurysms and infrarenal abdominal aortic aneurysms. However, endovascular techniques alone have been less applicable for treating complex aortic aneurysms, including those involving visceral vessels. Therefore, a hybrid open and endovascular approach with visceral debranching has become an increasingly favorable alternative for patients with these complex conditions. We report a case in which a staged hybrid approach was used for successful exclusion of an extensive thoracoabdominal aortic aneurysm in a symptomatic, high-risk patient who would not have been an appropriate candidate for open surgical repair.

Clinical outcomes of single versus staged hybrid repair for thoracoabdominal aortic aneurysm

OBJECTIVE

We investigated the outcomes of hybrid repair of thoracoabdominal aortic aneurysms and performed meta-analyses and meta-regressions to assess whether the number of stages during hybrid repair is associated with mortality.

METHODS

Review methods were according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The primary outcome was 30-day mortality. Secondary outcomes of procedural and clinical success were reported descriptively. Meta-analyses, meta-regressions, and logistic regressions were performed to estimate the odds ratio (OR) describing the association between the staging of the operation and in-hospital death.

RESULTS

We included 19 studies of 660 patients. Procedures were single-staged in 288 patients and staged in 372. Perioperative mortality ranged from 0% to 44.4%, and spinal cord ischemia ranged from 0% to 15.3%. After a mean follow-up of 26 months (range, 6-88.5 months), the overall mortality was 20.8%. The meta-regression of all studies' summary data (OR, 0.64; 95% confidence interval [CI], 0.19-2.16; P = .45; I(2) = 0.42) and a meta-regression where mortality rates in four studies were stratified by operative staging (OR, 0.57; 95% CI, 0.24-1.36; P = .19; I(2) = 0.38) supported a two-stage procedure but failed to reach statistical significance. Logistic regressions of individual patient data from a single center demonstrated evidence that a staged procedure was safer (adjusted OR, 0.04; 95% CI, 0.00-0.96; P < .05).

CONCLUSIONS

Hybrid repair of thoracoabdominal aortic aneurysms may reduce early morbidity and mortality even in a group considered high risk for open surgery but still carries risks of perioperative complications. This study suggested advantages to a staged procedure, but statistically significant evidence is lacking. Prospective data are still needed to optimize hybrid repair and best define its role.

Balloon-assisted coil embolization of the celiac trunk before endovascular aortic repair of thoracoabdominal aortic aneurysm

PURPOSE

Celiac trunk coil embolization before thoracic endovascular aneurysm repair (TEVAR) of a thoracoabdominal aortic aneurysm involving the celiac trunk can prevent type II endoleaks. One disadvantage of conventional coil embolization is the risk of coil displacement. We performed coil embolization under balloon occlusion of the celiac trunk to address this issue.

MATERIALS AND METHODS

Between December 2008 and January 2011, 5 patients (3 men and 2 women, mean age 76 years) were included in this study. For all patients, after confirming the collateral blood flow from the superior mesenteric artery via the pancreaticoduodenal arcades by using the balloon occlusion test, celiac trunk coil embolization proceeded under balloon occlusion of the proximal part of the celiac trunk.

RESULTS

Balloon-assisted coil embolization of the celiac trunk was completed for all patients without any complications. All coils were deployed as planned in the short segment of the celiac trunk without displacement. Coil migration, ischemic complications, and endoleaks via the celiac trunk did not arise in any of the patients over a follow-up period of 77-637 (mean 258) days.

CONCLUSIONS

Balloon-assisted coil embolization of the celiac trunk before TEVAR could be a feasible treatment option for suitable patients.

Treatment of a rapidly expanding thoracoabdominal aortic aneurysm after endovascular repair of descending thoracic aortic aneurysm in an old patient

Background

Aortic pathology progression and/or procedure related complications following endovascular repair should always be considered mostly in older patients. We herein describe a hybrid procedure for treatment of rapidly expanding thoracoabdominal aneurysm following endovascular treatment of a descending thoracic aortic aneurysm in an older patient.

Case presentation

A 82-year-old man at 18 months after endovascular surgery for a contained rupture of descending thoracic aortic aneurysm revealed a type IV thoracoabdominal aneurysm with significant increase of the aortic diameters at superior mesenteric and renal artery levels. A hybrid approach consisting of preventive visceral vessel revascularization and endovascular repair of entire abdominal aorta was performed. Under general anaesthesia and by xyphopubic laparotomy, the infrarenal aneurysmatic aorta and common iliac arteries were replaced by a bifurcated woven prosthetic graf. From each of the prosthetic branches two reverse 14x7 mm bifurcated PTFE prosthetic grafts were anastomized to both renal arteries and to the celiac axis and superior mesenteric artery, respectively. Vessel ischemia was restricted to the time required for anastomosis. Three 10 cm Gore endovascular stent-grafts for a total length of 15 cm, were used. The overlapping of the stent-grafts was carried out from the bottom upwards, starting from the aorto-iliac prosthetic body up to the healthy segment of thoracic aorta, 40 mm from the previous stent-grafts.

The patient was discharged on the 9th postoperative day.

Conclusion

This technique offers the advantage of a less invasive treatment, reducing the risk of paraplegia, visceral ischaemia and pulmonary complications, mostly in older patients.

Hybrid Open Endovascular Technique for Aortic Thoracoabdominal Pathologies

Background—

Many authors using a hybrid debranching strategy for the treatment of thoracoabdominal pathologies have reported disappointing results and the initial enthusiasm for the technique has given way to criticism and ambiguity. The aim of the present meta-analysis study was to assess the safety and efficacy of the technique in patients with thoracoabdominal aortic aneurysms or other aortic pathologies.

Methods and Results—

A multiple electronic search was performed on all articles describing hybrid open endovascular repair. Separate meta-analyses were conducted for technical success, visceral graft patency, spinal cord ischemia symptoms, renal insufficiency, and other complications as well as 30-day/in-hospital mortality.

Nineteen publications with a total of 507 patients were analyzed. The pooled estimates for primary technical success and visceral graft patency were 96.2% (95% CI, 93.5%–98.2%) and 96.5% (95% CI, 95.2%–97.8%) respectively. A pooled rate of 7.5% (95% CI, 5.0%–11.0%) for overall spinal cord ischemia symptoms was observed; whereas for irreversible paraplegia the pooled rate was 4.5% (95% CI, 2.5%–7.0%). The pooled estimate for renal failure was 8.8% (95% CI, 3.9%–15.5%). The pooled 30-day/in-hospital mortality rate was 12.8% (95% CI, 8.6%–17.0%). During the mean follow-up period of 34.5 (95% CI, 31.5–37.5) months, a total of 119 endoleaks were identified in 111 patients (22.7%).

Conclusions—

The repair of thoracoabdominal pathologies by means of hybrid procedures in patients who are poor surgical candidates is still associated with significant morbidity and mortality rates. Future studies may substantiate whether the technique is amenable to amelioration and improvement.

Initial experience in the treatment of thoracic aortic aneurysmal disease with a thoracic aortic endograft at Baylor University Medical Center

A retrospective review of 27 patients who underwent endovascular repair of thoracic aneurysms and of other thoracic aortic pathology with the thoracic aortic endograft (Gore Medical, Flagstaff, AZ) from June 2005 to July 2007 was performed. The mean follow-up period was 13.5 months (range, 2-25 months). Indications for thoracic endografting included descending thoracic aneurysms (n = 18), thoracoabdominal aneurysms (n = 3), traumatic aortic injuries (n = 3), penetrating aortic ulcers (n = 2), and contained rupture of a type B dissection (n = 1). One patient died during the procedure, for an overall mortality rate of 3.7%. The average length of stay was 8.1 days, with an average stay in the intensive care unit of 4.2 days. If patients with traumatic aortic injuries were excluded, the average overall and intensive care unit length of stay were 5.6 and 1.8 days, respectively. There was one incident of spinal cord ischemia (3.7%). There were five type I or type III endoleaks, three of which required revision (11.1%). In conclusion, thoracic endografting is a safe and viable option for the repair of descending thoracic aneurysms and other aortic pathologies. We have found it to be less invasive, even in conjunction with preoperative debranching procedures, with a shorter recovery time, decreased perioperative morbidity and blood loss, and decreased peri-operative mortality compared with standard open repair.

Recent advances in thoraco-abdominal aortic aneurysm repair

Thoraco-abdominal aortic aneurysm repair remains a formidable challenge to vascular surgeons. The traditional repair of thoraco-laparotomy with aortic cross-clamping is associated with a high morbidity and mortality despite significant advances in perioperative critical care, anaesthetic and surgical techniques. The advent of the endovascular revolution has shown a marked paradigm in the approach to all aneurysm repairs. As a logical progression from the open repair, the St Mary's visceral hybrid repair combines traditional open techniques (retrograde visceral and renal revascularisation via mid-line laparotomy) with endovascular stent grafting, thereby avoiding the need for thoracotomy and aortic cross-clamping. In specialist centres, the results have been encouraging and easily comparable to the open repair. The technique has been used in several centres around the world and represents a robust, transferrable method of repairing thoraco-abdominal aortic aneurysms. Stent-grafting technologies have reached a point of sophistication that wholly endovascular methods of repairing thoraco-abdominal aortic aneurysms are being performed in several centres around the world. Although these stent grafts have to be customised to the individual patient and are only suitable for certain types of aneurysmal anatomies, they represent the future of thoraco-abdominal aortic aneurysm repair. We review the history of thoraco-abdominal aortic aneurysm repair, the exciting advances in their treatment and discuss our approach to the management of thoraco-abdominal aortic aneurysms in the 21st century.

Endovascular repair in the thoracic and abdominal aorta: no increased risk of spinal cord ischemia when both territories are treated

PURPOSE

To evaluate the morbidity associated with thoracic and abdominal aortic repair using endovascular exclusion alone or combined endovascular and open repair.

METHODS

Between January 1998 and February 2007, 49 patients (36 men; mean age 70 years) underwent treatment for thoracic and abdominal aorta disease with descending thoracic aortic (DTA) stent-graft and abdominal aortic repair. Thirty-nine patients with coexisting thoracic and abdominal pathologies were classified with multilevel aortic disease (MLAD), whereas 10 patients presented with thoracoabdominal aneurysm. Patients were separated into 3 groups: 1: thoracic stent-grafts and open abdominal repair (n = 18), group 2: thoracic and abdominal stent-grafts (n = 21), and group 3: thoracic stent-grafts with visceral artery debranching (n = 10). Prior carotid-subclavian bypass was performed in 3 (6%) patients with a dominant left vertebral artery.

RESULTS

Stent-graft deployment was technically successful in all cases. Eight (16%) patients underwent emergent thoracic stent-graft placement. In 9 (18%) patients, the left subclavian artery was covered. No incidence of spinal cord ischemia was observed. The 30-day mortality was 4%, and overall mortality was 6% over a mean 33-month follow-up. The endoleak rate was 6% (1 type I, 1 type II, and 1 type III).

CONCLUSION

Conventional or endovascular abdominal open repair in combination with DTA stent-grafting is feasible and a safe alternative to traditional open repair. Management of MLAD did not show increased incidence of spinal cord ischemia and was associated with fewer complications and deaths than simultaneous or staged open thoracic and abdominal repairs.

Hybrid repair of thoracoabdominal aneurysms: a combined endovascular and open approach

Thoracic endografting is emerging as an alternative option in the surgical management of patients who have thoracoabdominal aortic aneurysms (TAAA) or aortic dissection. Due to the high morbidity and mortality rates associated with open TAAA repair, vascular surgeons are searching for innovative methods to repair such aneurysms. A combined endovascular and open approach, otherwise known as the hybrid repair, involves aortic "debranching" (renal and mesenteric revascularization) to create a landing zone for the endograft. Although operative mortality with hybrid is equivalent to mortality found with open repair, reported paralysis rates are reduced. Limited data regarding hybrid graft patency and durability are available. Vascular nurses play a vital role in patient education pre and postoperatively; therefore, they should know the risks and benefits associated with both open and hybrid TAAA repair as well as the risk associated with TAAA rupture. Nurses caring for patients after hybrid repair should possess astute assessment skills in monitoring for postoperative complications. Close observation for stroke, paralysis, renal insufficiency/failure, bowel ischemia/dysfunction, lower extremity ischemia and basic hemodynamics is essential for favorable outcomes. Vascular nurses should provide surgery-specific instruction regarding lengths of stay, expected outcomes, activity restrictions, CT-scan follow-up and possible complications after surgery, including warning signs. In the evolving field of endovascular surgery, vascular nurses must remain current on new innovative techniques being used, such as thoracic endografting.

A novel hybrid device for avoiding redo surgery in synchronous iliac and femoral peri-anastomotic pseudo-aneurysms

Synchronous peri-anastomotic pseudo-aneurysms were discovered in a 65-year-old man 26 years after an aorto-bi-iliac bypass and 11 years after an ileo-femoral bypass. He was a poor surgical candidate owing to his obesity, hostile abdomen, and multiple medical comorbidities. Therefore, a novel hybrid device was designed that was part stent graft with the addition of two 6-mm Dacron limbs for anastomosis onto the superficial femoral and profunda femoris arteries. An unexpected type 2 endoleak developed through the internal iliac artery, which was thought to be occluded. This was successfully treated with a direct injection of bovine thrombin. This was an excellent outcome, and the patient made an uneventful recovery.

Use of the abdominal aorta as an alternative access site for thoracic aortic stent graft placement

The treatment of thoracic aortic pathology has undergone a paradigm shift in recent years, with a trend toward less invasive endovascular techniques and away from open surgical repair. Reports on the successful use of endografts in the thoracic aorta have demonstrated decreased morbidity and mortality of these procedures compared with traditional open repair. However, some patients are not candidates for an endovascular approach because of a short proximal landing zone, arch angulation, luminal irregularities, or a large diameter of the transverse arch and the proximal descending aorta. Other patients are excluded because of distal pathology or anatomic irregularities. This article presents 2 patients with thoracic aortic pathology, and both had inadequate proximal landing zones and small, calcified iliac arteries prohibiting femoral or iliac access. Successful repair of these patients was achieved by a staged procedure using a brachiocephalic debranching technique, followed by direct infrarenal aortic cannulation through a limited celiotomy.

Hybrid procedures for thoracoabdominal aortic aneurysms and chronic aortic dissections - a single center experience in 28 patients

OBJECTIVE

We report our 6-year experience with the visceral hybrid procedure for high-risk patients with thoracoabdominal aortic aneurysms (TAAA) and chronic expanding aortic dissections (CEAD).

METHODS

Hybrid procedure includes debranching of the visceral and renal arteries followed by endovascular exclusion of the aneurysm. A series of 28 patients (20 male, mean age 66 years) were treated between January 2001 and July 2007. Sixteen patients had TAAAs type I-III, one type IV, four thoracoabdominal placque ruptures, and seven patients CEAD. Patients were treated for asymptomatic, symptomatic, and ruptured aortic pathologies in 20, and 4 patients, respectively. Two patients had Marfan's syndrome; 61% had previous infrarenal aortic surgery. The infrarenal aorta was the distal landing zone in 70%. In elective cases, simultaneous approach (n = 9, group I) and staged approach (n = 11, group II) were performed. Mean follow-up is 22 months (range 0.1-78).

RESULTS

Primary technical success was achieved in 89%. All stent grafts were implanted in the entire thoracoabdominal aorta. Additionally, three patients had previous complete arch vessel revascularization. Left subclavian artery was intentionally covered in three patients (11%). Thirty-day mortality rate was 14.3% (4/28). One patient had a rupture before the staged endovascular procedure and died. Overall survival rate at 3 years was 70%, in group I 80%, and in group II 60% (P = .234). Type I endoleak rate was 8%. Permanent paraplegia rate was 11%. Three patients required long-term dialysis (11%). Peripheral graft occlusion rate was 11% at 30 days. Gut infarction with consecutive bowel resection occurred in two patients. There was no significant difference between group I and II regarding paraplegia and complications.

CONCLUSIONS

Early results of visceral hybrid repair for high-risk patients with complex and extended TAAAs and CEADs are encouraging in a selected group of high risk patients in whom open repair is hazardous and branched endografts are not yet optional.

[Thoracoabdominal aortic aneurysm hybrid repair]

Introduction of endografting has significantly changed the treatment options of aortic aneurysms; they can be successfully applied for aortic arch or thoracoabdominal aorta aneurysm repairs, as well. In order to create safe landing zones for the endografts on these segments, a modification of the original anatomy is needed using transpositions and/or bypasses, which is called "debranching". These hybrid procedures that combine traditional and endovascular techniques may reduce surgical trauma and offer solution for patients being unfit for major surgery. We carried out a hybrid intervention in a lady who had a 60 mm Crawford Type IV aortic aneurysm including the orifice of the celiac trunk. First, an aorto-splenic artery PTFE bypass was performed and the celiac trunk was oversewn proximally to its trifurcation. The spleen remained viable through the gastroepiploic artery. Four days thereafter we covered the aneurysm using a 34 mm Thoracic Excluder. The patient tolerated both procedures well, and was discharged in stable condition. One year after this intervention, a follow-up CT scan confirmed the good position of the endograft, no endoleak and involution of the aneurysm was detected. Good patency of the aorto-splenic artery bypass was seen. This was the first thoracoabdominal hybrid surgery case performed in Hungary.

Hybrid Open-endovascular Repair for Thoracoabdominal Aortic Aneurysms: Current Status and Level of Evidence

PURPOSE

To report the results of a systematic review of the literature and to provide evidence for the hybrid open-endovascular repair (HOER) in patients with thoracoabdominal aortic aneurysms (TAAAs).

METHODS

A comprehensive literature review was performed and all studies identified that reported the results of HOER in patients with TAAA and information about primary technical and clinical success in evaluating the immediate and long-term complications such as neurological, renal and respiratory morbidity. All studies were reviewed by two independent observers for the above mentioned parameters.

RESULTS

After careful selection according to the given criteria, 13 studies were included in our statistical analysis. The number of reported patients totalled 58. Of those, 37 were men (64.4%) and the mean age of the patients was 68.1 years (range 35-80, 95%CI [72.8, 64.9]). All patients were unfit for open repair with severe comorbidities. The mean follow-up period was 14.5+/-8.7 months (range 4-36, 95%CI [18.7, 9.9]) and the mean aneurysm diameter was 7.15cm (range 5 to 12, 95%CI [7.87, 6.69]). 229 (97.8%) of the 234 visceral vessel grafts remained patent during the follow-up period. Reintervention was necessary in one (1.6%) of the five patients with an occluded graft. The overall long-term endoleak rate was 20.6% (12/58 patients) and the reintervention rate was 13.7% (8/58 patients). No patients developed procedure-related neurological deficits. The overall early and long-term mortality rate for completed procedures was 15.5% (9/58).

CONCLUSIONS

HOER shows promising mid-term results for high-risk patients who have TAAA, however, present evidence does not allow robust conclusions.

Early Results after Staged Hybrid Repair of Thoracoabdominal Aortic Aneurysms

BACKGROUND

The morbidity and mortality rates associated with open thoracoabdominal aortic aneurysm (TAAA) repair are substantial. This study was designed to review our early experience with the hybrid endovascular and, or open approach for TAAA repair.

STUDY DESIGN

Patients undergoing elective hybrid repair of their TAAAs were retrospectively reviewed.

RESULTS

Seventeen patients (mean age 69+/-15 years, male, 76%) underwent visceral and renal revascularization as the first stage of their hybrid repair. The Crawford extent included: II, 2; III, 8; and IV, 7. Perioperative mortality and complication rates after the first stage were 24% and 25%, respectively; the mean intensive care unit stay and total length of stay were 7+/-12 days (range 1 to 45 days) and 22+/-33 days (range 3 to 100 days), respectively. The endovascular aneurysm repair or second stage procedure was performed in 12 of 13 (92%) of the surviving patients, with a mean of 27+/-27 days (range 6 to 99 days) between the procedures. Two patients experienced intraoperative complications during the second stage, but there were no deaths or additional postoperative complications. Patients did not require the intensive care unit, and the overall mean length of stay after the second stage was 2+/-2 days (range 1 to 5 days). The mean postoperative followup among the 11 patients completing both stages was 8+/-12 months (range 1 to 15 months). The primary patency rate for the visceral and renal bypasses was 96% (54 of 56).

CONCLUSIONS

The hybrid approach for patients with TAAAs may reduce complications in the average, low-risk patient and may extend the indications for repair to patients considered higher risk based on age, comorbidities, or anatomic considerations.