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Liu T, Zhao J, Sun J, Wu K, Wang W. Comparison of efficiency and safety of open surgery, hybrid surgery and endovascular repair for the treatment of thoracoabdominal aneurysms: a systemic review and network meta-analysis. Front Cardiovasc Med 2023; 10:1257628. [PMID: 38162130 PMCID: PMC10757346 DOI: 10.3389/fcvm.2023.1257628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/16/2023] [Indexed: 01/03/2024] Open
Abstract
Objective The objective of this study was to perform a network meta-analysis (NMA) to assess the efficacy and safety of three different surgical interventions- open surgical repair (OSR), hybrid surgical repair (HSR), and endovascular repair (EVAR)- for the treatment of thoracoabdominal aortic aneurysms (TAAAs). Methods Electronic repositories like PubMed, Embase, Web of Science, Scopus, ScienceDirect, the Cochrane library, Clinical trial, and China National Knowledge Infrastructure (CNKI) were systematically searched to identify studies that compared the efficacy of OSR, HSR, and EVAR with endografts for the treatment of TAAAs until December 24th, 2022. Random-effects and fixed-effects models were employed to analyze the data gathered in a network meta-analysis. The study's primary outcomes of interest encompassed in-hospital mortality, long-term survival rate, and postoperative complications. Results Eleven comparative studies meet inclusion criterias. There were 2,222 patients in OSR, 1,574 patients in EVAR and 537 patients in HSR. EVAR has lower one-month mortality than OSR (RR: 0.31; 95% CI: 0.17-0.70) and HSR (RR: 0.37; 95% CI: 0.22-0.71), and lower incident rate of renal complications than HSR (RR: 0.20; 95% CI: 0.08-0.43) and OSR (RR: 0.34; 95% CI: 0.16-0.65). Nonetheless, there was no noteworthy discrepancy identified in the long-term survival rates of these procedures. Conclusions As compared with OSR, HSR, and EVAR, EVER has lower one-month mortality, and lower incident rates of complications. Systematic review registration PROSPERO (CRD42022313829).
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Affiliation(s)
- Tinghua Liu
- Department of Vascular Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Jiani Zhao
- Department of Vascular Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Jinjian Sun
- Department of Vascular Surgery, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Kemin Wu
- Department of Vascular Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Wei Wang
- Department of Vascular Surgery, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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Muston BT, Bilbrough J, Bushati Y, Wilson-Smith AR, Misfeld M, Yan T. Open, closed or a bit of both: a systematic review and meta-analysis of staged thoraco-abdominal aortic aneurysm repair. Ann Cardiothorac Surg 2023; 12:418-428. [PMID: 37817847 PMCID: PMC10561333 DOI: 10.21037/acs-2023-scp-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/22/2023] [Indexed: 10/12/2023]
Abstract
Background Staged procedures are one strategy found to be beneficial for medium- to high-risk Crawford extent I-III thoraco-abdominal aortic aneurysm (TAAA) repair patients and may be performed through a variety of techniques. This review sought to compare the primary outcomes of spinal cord ischemia (SCI) and long-term mortality between three cohorts grouped by approach: open, endovascular, and hybrid. Methods In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a total of 919 references were extracted from a search of three online databases (Embase, PubMed, Scopus). Following application of inclusion/exclusion criteria and data extraction, quantitative meta-analysis was undertaken utilizing a random effects model. Kaplan-Meier (KM) curves were digitized and aggregated to graph estimated survival. Results A total of 20 studies representing 924 patients were included. SCI was highest in the endovascular group, at 9.8% of weighted means, followed by hybrid, and open groups at 3.2% and 1.4%, respectively. However, 30-day mortality was highest in the open group at 6.0%, followed by the hybrid group at 3.8%, and endovascular at 3.6%. Aggregated long-term survival estimations are shown graphically, extending to 5 years for open and endovascular cohorts, and 3 years for the smaller hybrid cohort. Conclusions While all cases incorporated spinal drainage, monitoring and staging for spinal protection, there is innate difference in approach when examining for cord ischemia. This systematic review and meta-analysis of staged TAAA repair describes the first comparison between cohorts of open and endovascular approach, revealing the increased risk of SCI and long-term mortality in endovascular repair.
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Affiliation(s)
- Benjamin T Muston
- The Collaborative Research Group (CORE), Sydney, Australia
- Faculty of Medicine and Health, The University of New South Wales, Sydney, Australia
| | - James Bilbrough
- Faculty of Medicine and Health, The University of New South Wales, Sydney, Australia
| | - Ymer Bushati
- Faculty of Medicine and Health, The University of New South Wales, Sydney, Australia
| | - Ashley R Wilson-Smith
- The Collaborative Research Group (CORE), Sydney, Australia
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Martin Misfeld
- The Collaborative Research Group (CORE), Sydney, Australia
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Tristan Yan
- The Collaborative Research Group (CORE), Sydney, Australia
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
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Hu Z, Zhang Z, Liu H, Chen Z. Fenestrated and Branched Stent-Grafts for the Treatment of Thoracoabdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:901193. [PMID: 35711352 PMCID: PMC9197478 DOI: 10.3389/fcvm.2022.901193] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/04/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose To investigate the safety and efficacy of total endovascular repair for thoracoabdominal aortic aneurysms (TAAAs) with fenestrated and branched stent-grafts. Methods The MEDLINE, EMBASE, and Cochrane databases were searched between January 2001 and December 2021 to identify literature relevant to the use of fenestrated and branched endografts for the treatment of TAAAs. Studies with <4 cases and those on juxtarenal or pararenal aortic aneurysms were excluded. Meta-analyses were conducted to evaluate spinal cord ischemia (SCI), irreversible SCI, renal insufficiency, dialysis, endoleak, reintervention, target vessel patency, 30-day mortality and overall mortality. Fourteen studies comprising 1,114 patients (mean age 72.42 years, 847 men) were selected. The mean TAAA diameter was 67 mm. The Crawford TAAA classification was type I-III in 759 cases, type IV in 344 cases, and type V in 10 cases. Outcomes of the meta-analysis are reported as proportions and 95% confidence intervals (CIs). Results The pooled rates for 30-day mortality and overall mortality were 6% and 18%, respectively. The pooled rate for technical success was 94% (95% CI, 93–96%), for SCI was 8% (95% CI, 7–10%), for irreversible SCI was 6% (95% CI, 4–7%), for reversible SCI was 5% (95% CI, 4–6%), for reversible SCI was 2% (95% CI, 2–3%), for renal insufficiency was 7% (95% CI, 5–10%), for dialysis was 3% (95% CI, 2–4%), for target vessel patency was 98% (95% CI, 97–99%), and for reintervention was 15% (95% CI, 9–24%). Conclusion Fenestrated and branched endografts for the treatment of TAAAs are safe and effective with acceptable early results. Lifelong regular follow-up and additional prospective studies are necessary to substantiate whether this technique is valid.
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Saitto G, Scafuri A, Kuci S, Ibrahimi A, Zeitani J. A Novel Endosurgical Prosthesis to Treat Thoracoabdominal Aortic Aneurysm in Complex Anatomy or Emergency Settings. AORTA (STAMFORD, CONN.) 2020; 8:25-28. [PMID: 32736400 PMCID: PMC7445134 DOI: 10.1055/s-0040-1702143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 11/18/2019] [Indexed: 06/11/2023]
Abstract
BACKGROUND Despite improvements in operative techniques, open thoracoabdominal aortic aneurysm (TAAA) repair is complex and characterized by high mortality and morbidity rate. Less invasive techniques have been developed since 2005 for the treatment of TAAA. Unfortunately, many of these devices require custom fabrication, resulting in delay of many weeks until treatment can be delivered but crucial in critical emergency cases. We present a novel hybrid endovascular and surgical prosthesis, which was tested on five pigs, with the aim of reducing the barrier issues of endovascular therapy in such particular cases. METHODS The principal characteristic of the proposed hybrid endovascular prosthesis is to combine a proximal and distal stented zones and, in between, a classical surgical blood tied Dacron prosthesis. The device was tested in five pigs where feasibility of implantation and acute postoperative outcomes were evaluated, including bleeding, bowel ischemia, renal function, and peripheral blood perfusion. RESULTS In all cases, following laparotomy, the endoprosthesis was successfully implanted under fluoroscopy and the surgical prosthesis zone could be easily detected by the radio-opaque markers. No major bleeding or cardiac events occurred throughout preparation and implantation. One hour after prosthesis implantation and surgical anastomoses of all vessels were completed, normal urine output was registered, and no acidosis was detected. CONCLUSIONS This novel graft has shown ease of endoprosthesis and visceral vessels implantation without the need of thoracotomy or extracorporeal circulation and may be useful in an emergency setting or high risk and complex anatomy TAAA unsuitable for traditional endovascular aneurysm repair, or to avoid an excess waiting time for a "custom made" prosthesis. The great adaptability of this "hybrid" prosthesis in complex anatomy for the majority of TAAA could be important in high-risk patients and in some difficult situations, such as a high risk of imminent rupture.
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Affiliation(s)
- Guglielmo Saitto
- Department of Cardiac Surgery, Istituto di ricovero e cura a carattere scientifico, San Donato Milanese Hospital, San Donato Milanese, Italy
| | - Antonio Scafuri
- Department of Cardiac Surgery, Tor Vergata University of Rome, Rome, Italy
| | - Saimir Kuci
- Department of Anesthesiology, Reanimation Mother Teresa University, Tirana, Albania
| | - Alfred Ibrahimi
- Department of Anesthesiology, Reanimation Mother Teresa University, Tirana, Albania
| | - Jacob Zeitani
- Department of Biomedical Sciences and Specialized Surgery, University of Ferrara, Ferrara, Italy
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Orozco-Sevilla V, Weldon SA, Coselli JS. Hybrid thoracoabdominal aortic aneurysm repair: is the future here? J Vis Surg 2018; 4:61. [PMID: 29682471 DOI: 10.21037/jovs.2018.02.14] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/08/2018] [Indexed: 11/06/2022]
Abstract
Open surgical repair has been the gold standard for thoracoabdominal aortic aneurysm (TAAA) repair for more than 6 decades, but 2 additional options have emerged: total endovascular TAAA repair and a hybrid approach that combines open and endovascular repair. Despite the optimism for an endovascular approach, long-term results for these repairs are still lacking. Some of the issues with this emerging technology include the risk of paraplegia after extensive endovascular repair, the need for multiple reinterventions, continuous stent-graft surveillance, endograft branch stenosis, as well as the significant learning curve. Interest in a hybrid approach has resurged despite the non-superior results compared to open TAAA. Commonly, the focus of the hybrid approach is now on performing a less extensive open TAAA repair, which is then extended with a stent-graft or vice versa. Moreover, this approach is now often performed in two stages in an effort to decrease the associated spinal cord ischemia. Open surgical repair after endovascular aortic repair is increasingly being performed to address serious complications, such as infection or fistula, that cannot be repaired by further endovascular intervention. As with any new technology, there will be an increase in the number of procedure-related complications and a decrease in the number of surgeons who can perform the traditional open operation with good results.
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Affiliation(s)
- Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Section of Adult Cardiac Surgery, Texas Heart Institute, Houston, Texas, USA.,CHI St. Luke's Health-Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Scott A Weldon
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Section of Adult Cardiac Surgery, Texas Heart Institute, Houston, Texas, USA.,CHI St. Luke's Health-Baylor St. Luke's Medical Center, Houston, Texas, USA
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Komarov RN, Vinokurov IA, Karavaykin PA, Abdulmutalibov IM, Belov YV. [Staged approach for hybrid thoracoabdominal aortic replacement]. Khirurgiia (Mosk) 2018:21-27. [PMID: 29460875 DOI: 10.17116/hirurgia2018221-27] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
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.
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Affiliation(s)
- R N Komarov
- Sechenov First Moscow State Medical University Cardiac Surgery Department #2, Moscow, Russia
| | - I A Vinokurov
- Sechenov First Moscow State Medical University Cardiac Surgery Department #2, Moscow, Russia
| | - P A Karavaykin
- Sechenov First Moscow State Medical University Cardiac Surgery Department #2, Moscow, Russia
| | - I M Abdulmutalibov
- Sechenov First Moscow State Medical University Cardiac Surgery Department #2, Moscow, Russia
| | - Yu V Belov
- Sechenov First Moscow State Medical University Cardiac Surgery Department #2, Moscow, Russia
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Alonso Pérez M, Llaneza Coto JM, Del Castro Madrazo JA, Fernández Prendes C, González Gay M, Zanabili Al-Sibbai A. Debranching aortic surgery. J Thorac Dis 2017; 9:S465-S477. [PMID: 28616343 DOI: 10.21037/jtd.2017.03.87] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Manuel Alonso Pérez
- Vascular Surgery Department, Hospital Universitario Central de Asturias, Oviedo, Spain
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Benrashid E, Wang H, Andersen ND, Keenan JE, McCann RL, Hughes GC. Complementary roles of open and hybrid approaches to thoracoabdominal aortic aneurysm repair. J Vasc Surg 2016; 64:1228-1238. [PMID: 27444368 DOI: 10.1016/j.jvs.2016.04.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 04/15/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Thoracoabdominal aortic aneurysm (TAAA) repair remains a significant challenge with considerable perioperative morbidity and mortality. A hybrid approach utilizing visceral debranching with endovascular aneurysm exclusion has been used to treat high-risk patients and therefore allow repair in more patients. Limited data exist regarding long-term outcomes with this procedure as well as comparison to conventional open repair. This study describes our institutional algorithmic approach to TAAA repair using both open and hybrid techniques. METHODS Hybrid and open TAAA repairs performed between July 2005 and August 2015 were identified from a prospectively maintained institutional aortic surgery database. Perioperative morbidity and mortality, freedom from reintervention, and long-term and aorta-specific survival were calculated and compared between the two groups. RESULTS During the study period, 165 consecutive TAAA repairs were performed, including 84 open repairs and 81 hybrid repairs. Patients in the hybrid repair group were significantly older, were more frequently female, and had a generally greater comorbid disease burden, including significantly more chronic kidney disease. Despite the older and sicker cohort, there was no difference in in-hospital mortality between the two groups (9.9% hybrid vs 7.1% open; P = .59). Major morbidity rates differed by procedure, with patients undergoing open repair having a significantly higher rate of postoperative stroke (9.5% open vs 0% hybrid; P = .017), whereas patients undergoing hybrid repair had a higher rate of new permanent dialysis (14.8% hybrid vs 3.6% open; P = .043). There was no difference between groups in the rate of postoperative permanent paraplegia/paresis (8.3% open vs 7.4% hybrid; P = .294). There was a significantly increased rate of reintervention in the hybrid repair group (12.3% hybrid vs 1.2% open, P = .004), with all hybrid reinterventions performed because of endoleak. One-year survival was similar between groups at 69% in hybrid repairs vs 77% in open repairs. Long-term survival was worse in the hybrid group (5-year survival, 32% hybrid vs 56% open), although late survival appeared to be influenced mainly by comorbid disease burden, given the similar long-term aorta-specific survival between groups. CONCLUSIONS Use of an algorithmic approach whereby higher risk patients with TAAA are treated by a hybrid approach and lower risk patients with conventional open repair yields satisfactory short- and long-term outcomes. The availability of multiple options for TAAA repair within a single center likely allows repair in more patients with consequent decrease in the risk of aorta-related death, at the expense of increased reinterventions for endoleak.
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Affiliation(s)
- Ehsan Benrashid
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Hanghang Wang
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Nicholas D Andersen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey E Keenan
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Richard L McCann
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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Damrauer SM, Fairman RM. Visceral Debranching for the Treatment of Thoracoabdominal Aortic Aneurysms: Based on a Presentation at the 2013 VEITH Symposium, November 19-23, 2013 (New York, NY, USA). AORTA (STAMFORD, CONN.) 2015; 3:67-74. [PMID: 26798760 PMCID: PMC4686352 DOI: 10.12945/j.aorta.2015.14-066] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 03/05/2015] [Indexed: 06/05/2023]
Abstract
Surgical repair of thoracoabdominal aortic aneurysms (TAAA) is associated with significant morbidity and mortality. Hybrid approaches that involve visceral debranching and aortic endografting allow for an alternative approach in certain high-risk patients. In most circumstances the visceral vessels can be bypassed in a retrograde manner from the iliac arteries via a midline laparotomy, and the aortic aneurysm subsequently excluded with standard aortic endografts. These procedures avoid the extensive two-cavity exposure, aortic cross-clamping, and mechanical circulatory support that comprise open TAAA repair, and offer the theoretical advantage of being less invasive. Despite this, outcomes have been mixed with reported perioperative mortality rates of 0% and 34% and permanent paraplegia rates of 0% to 13% in most major series. The reported outcomes, as well as the variation between centers, highlight the importance of patient selection in undertaking hybrid repair. In practice, the best outcomes are achieved in patients who have high-risk anatomy, rather than high-risk comorbidities.
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Affiliation(s)
| | - Ron M. Fairman
- Corresponding Author: Ron M. Fairman, MD Division of Vascular Surgery and Endovascular Therapy Hospital of the University of Pennsylvania Philadelphia, Pennsylvania 19104, USA Tel: +1 215 614 0243, Fax: +1 215 662 4871, E-mail:
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