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

Management of a Large Abdominal Aortic Aneurysm in Conjunction with a Massive Inguinal Hernia

The majority of inguinal hernias that are concomitant with abdominal aortic aneurysms (AAAs) are clinically insignificant. However, management of AAA associated with a complex hernia can be challenging. We report a case of a 72-year-old male with a 7-cm AAA and a massive inguinal hernia involving loss of abdominal domain. Using a multidisciplinary approach, a staged hybrid endovascular and open repair of the AAA was performed followed by hernia repair.

Review of Treatment for Thoracoabdominal Aortic Aneurysm, and the Modern Experience of Multi-Branched Endograft in Taiwan

Thoracoabdominal aortic aneurysm (TAAA) is a complicated aortic disease. Most treatments for other aortic aneurysms have already shifted from conventional open surgery to endovascular operation; but for TAAA, open surgery remains the gold standard treatment. Several alternative treatments such as hybrid operation as well as endovascular techniques are utilized for the treatment of TAAA. Some of the procedures combine off-the-shelf devices such as the chimney procedure. Some other procedures required custom-made specialized stent grafts. A new off-the-shelf multi-branched endograft, T-branch graft, was released in late 2012, though it was not introduced into Taiwan until 2015. Ultimately, also we plan to report the experience of multi-branched endograft in Taiwan.

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.

Fenestrated stent graft in treatment of type IV thoracoabdominal aneurysm involving all visceral arteries

Conventional open surgical repair of thoracoabdominal aortic aneurysm (TAAA) is associated with high perioperative mortality and morbidity risk. Our report of successful treatment of a 56-year-old patient with TAAA involving all visceral arteries and with many comorbidities with a fenestrated stent graft supports its application in high-risk TAAA patients.

Editor's choice--hybrid treatment of thoracic, thoracoabdominal, and abdominal aortic aneurysms: a multicenter retrospective study

OBJECTIVES

The aim of this study was to assess the results of hybrid techniques for the treatment of thoracic, thoracoabdominal, and abdominal aortic aneurysms based on multicenter results and the various series regarding hybrid procedures reported in the literature.

METHODS

The results of 76 hybrid procedures performed in 19 French university hospital centers between November 2001 and October 2011 were collected. There were 50 men and 26 women, mean age 68.2 (35-86) years. All patients were considered at high risk (ASA≥3) for conventional surgery. Aneurysms involved the thoracic, abdominal, and thoracoabdominal aorta in five, 14, and 57 cases respectively. There were 11 emergent repairs. The revascularization of four visceral arteries was performed in 38 cases. Between one and three visceral arteries were revascularized in the other cases. Visceral artery debranching and stent graft deployment were performed in a one-stage procedure in 53 cases and in a two-stage procedure in 23 cases.

RESULTS

There were 26 (34.2%) postoperative deaths. Nine of the survivors developed paraplegia, of which one resolved completely. Bowel ischemia occurred in 13 cases (17.1%), and one patient was treated by a superior mesenteric artery bypass. Four patients required long-term hemodialysis. Postoperative computed tomography scan showed a type II endoleak in two patients.

CONCLUSIONS

Morbidity and mortality in this study were greater than previously reported. Candidates for hybrid aortic repair should be carefully selected.

Endovascular repair of thoracoabdominal aortic aneurysm (TAAA): early experience

BACKGROUND

Repair of thoracoabdominal aortic aneurysms (TAAA) represents a considerable technical challenge. Since its first description in 1955, open repair of TAAA has been considered the gold standard of repair. Despite improvements in surgical techniques, spinal cord protection and post-operative critical care support, patients who undergo open repair are faced with a mortality rate of 5-35 %. We report the first Irish experience of endovascular management of TAAAs.

RESULTS

To date five patients have undergone endovascular repair; four had hybrid repair and one a fenestrated graft. The mean age of the patients was 66.8 ± 3.4 and the mean aneurysm diameter was 6.74 ± 0.6 cm. All patients were ASA III. Two-stage hybrid repair was associated with an increased risk of complications, prolonged intensive care unit and overall hospital stay. One patient died in the perioperative period due to rupture of their aneurysm between the two stages of their hybrid repair.

CONCLUSION

The role of endovascular techniques in the treatment of TAAA continues to evolve. Hybrid and complete endovascular repairs do not replace conventional repair, but provide an alternative for high-risk patients who might otherwise be denied treatment.

Eight-year follow-up of a high-risk patient treated for Crawford Type II thoracoabdominal aortic aneurysm (TAAA) with a multistage hybrid open-endovascular repair

The case of a patient with type II TAAA (thoracoabdominal aortic aneurysm), who underwent multistage hybrid procedure, is presented. This high-risk patient was excluded as ineligible for conventional open repair. At first, the bypass between both common carotid arteries was inserted. Then, the transperitoneal viscerorenal revascularization was performed to ensure blood perfusion. At the end, the stent graft from the aorta arch to its bifurcation was deployed with endovascular techniques. This stent graft covered left common carotid artery, left subclavian artery, visceral trunk, superior mesenteric artery and both renal arteries. The patient had been observed for eight years with relatively low complication rate. The hybrid open-endovascular repair (HOER) shows promising results in patients at prohibitive risk for classic reconstruction.

Hybrid one-stage approach to extensive atherosclerotic aneurysm of thoracoabdominal aorta

We report a 62-year-old man with an atherosclerotic Crawford type II aneurysm involving both common iliac arteries who underwent surgical revascularization of the visceral vessels and renal arteries from the ascending aorta and subsequent endovascular aneurysmal exclusion. Computed tomography imaging at 2 years showed complete exclusion of the aneurysm throughout the thoracoabdominal aorta, confirming the successful antegrade revascularization of visceral vessels and renal arteries. A hybrid approach to thoracoabdominal aneurysms using antegrade visceral and renal revascularization from the ascending aorta before endovascular repair is technically feasible and might constitute an attractive alternative to conventional surgical treatment.

Transcatheter embolization of a type II endoleak after hybrid repair for thoracoabdominal aortic aneurysm

Hybrid stent-graft procedures with visceral revascularization have been reported as an alternative treatment option for thoracoabdominal aortic aneurysms (TAAAs), although the potential advantages of reduced morbidity and mortality compared with open surgical repair have not been definitively demonstrated. Endovascular aneurysm repair is associated with endoleaks in as many as 20% of cases in some series, often requiring repeat intervention. In the present case, during follow-up after a hybrid TAAA repair, a patient developed a type II endoleak originating from a celiac artery that was not ligated at its origin. The endoleak was successfully treated by transcatheter coil embolization.

Hybrid and endovascular therapy for extensive thoracoabdominal aortic disease

The past 4 decades have witnessed tremendous strides in the evolution of endovascular technology with increased operator experience, greater availability of more sophisticated and versatile endovascular devices, and advances in imaging modalities. In an attempt to limit the physiologic derangements associated with aortic crossclamping and extensive tissue dissection during traditional open surgical repair of extensive thoracoabdominal aortic aneurysms, less invasive strategies have been explored using endovascular technology: hybrid approaches and solely endovascular techniques. This article describes these techniques and their advantages, their current role in thoracoabdominal aortic aneurysm repair and potential future developments in this field.

Endovascular management of acute bleeding following recent and late open abdominal aortic aneurysm repair

Open repair of abdominal aortic aneurysm is still considered the gold standard against which endovascular repair is measured. We describe two cases of open repair complicated by bleeding where endovascular treatment proved to be life-saving.

Experience with a Scalloped Thoracic Stent Graft: A Good Alternative to Preserve Flow to the Celiac and Superior Mesenteric Arteries and to Improve Distal Fixation and Sealing

Thoracic endografting has been proposed as an effective alternative to open repair to treat several aortic pathologies. Cranial migration is one of the critical issues concerning long-term durability. The scalloped thoracic endograft was proposed to improve distal sealing and fixation crossing the diaphragm. The objective of this study was to evaluate technical feasibility and experience with a custom-made scalloped thoracic endograft using the Relay platform (Bolton Medical, Sunrise, FL) in selected cases. From January 2006 to June 2009, 57 patients (40 men) were treated in Europe with a customized distal scalloped thoracic endograft. Forty-five patients presented with thoracic aortic aneurysm, nine presented with type B dissection, and three had a pseudoaneurysm. Successful and accurate deployment was achieved in all cases except one partial rotation in an extremely tortuous anatomy. Technical success was achieved in 96.4%. Good sealing and no mortality, paraplegia, or visceral embolization were observed. At a mean follow-up of 6 months, no complications were registered. The Relay endograft with the distal scallop represents a feasible alternative for distal short necks. This approach may increase the applicability and durability of the endograft in short distal necks.

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.

Hybrid Procedures for Complex Thoracoabdominal Aortic Aneurysms: Early Results and Secondary Interventions

Background: Hybrid procedures for thoracoabdominal aortic aneurysms (TAAA) have been previously described as an attractive alternative to open reconstruction.

Patients and Methods: Between 1999 and 2009, 16 patients with a median age of 67years underwent hybrid repair of a TAAA (Crawford type I: 3, type II: 3, type III: 1, and type IV: 9). In 94%, 3 and more severe comorbidities were present, with previous aortic surgery in 56% of the patients; elective/urgent repair was done in 10 and emergent surgery in 6 patients.

Results: Primary technical success was 100%, with 31 vessels grafted. Elective/urgent mortality was 20% (2 of 10) and emergent mortality 50% (3 of 6). During follow-up time (median: 12 months) 2 patients died and 2 patients had to undergo secondary interventions.

Conclusion: In high-risk patients especially after prior aortic surgery hybrid repair of TAAA is feasible. However, due to high mortality rates especially in the emergent situation this procedure should be reserved only for decidedly selected patients.

Hybrid procedures for complex aortic pathology: initial experience at a single center

INTRODUCTION AND OBJECTIVES

To review experience at our center with the use of hybrid techniques for treating complex aneurysms of the thoracic aorta.

METHODS

The medical records of 41 patients (40 male) with complex aortic aneurysms affecting supra-aortic or visceral vessels who underwent hybrid procedures between 1998 and 2007 were reviewed retrospectively. All patients were in American Society of Anesthesiologists category IV. They were divided in two groups: group A comprised 32 patients with aneurysms involving the aortic arch and its branches (2 ascending aorta replacements, 1 arch repair, 13 carotid-carotid bypasses, 12 carotid-subclavian bypasses, and 4 with total arch debranching); and group B comprised 9 patients with thoracoabdominal aneurysms and visceral vessel transpositions (4 partial and 5 total debranching). The mean age in group A was 69.3+/-1.3 (range, 62-73) years and in group B, 71.5+/-5.0 (range, 68-74) years.

RESULTS

The mean hospital stay was 18+/-7.1 days (range, 5-35) and 12+/-8.2 days (range, 2-15) in groups A and B, respectively. Overall mortality was 12.2% (3.4% and 44.4% in groups A and B, respectively) and neurological morbidity was 3.4% and 11.1% in the two groups, respectively.

CONCLUSIONS

The results obtained with hybrid treatment of the aortic arch area were comparable with those of conventional surgery. However, thoracoabdominal repair with complete revascularization of the visceral branches was associated with high mortality. Consequently, hybrid treatment is a valid option for high-risk patients who do not require complete revascularization in the visceral area.