Hybrid thoracoabdominal aortic aneurysm repair: is the future here?

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.

Offener thorakaler und thorakoabdominaler Aortenersatz vs. f/b(T)EVAR – komplementär oder kompetitiv?

“…10 % aller Aortenaneurysmen aus und wird klassischerweise nach Crawford oder modifiziert nach Safi eingeteilt, basierend auf den betroffenen Segmenten (▶ Abb. Diese Risiken steigen mit der Ausdehnung des Aneurysmas sowie dem Alter und den Komorbiditäten des Patienten [6,7]. Insbesondere schlechte Herzfunktion, KHK und COPD sind entscheidende Risikofaktoren mit Einfluss auf die postoperative Komplikationsund Sterblichkeitsrate [8,9].…”

“…Hybridverfahren, Parallel-Graft-Techniken, Physician-modified-Prothesen und z. B. In-situ-Fenestrierungen erlauben schnelle Modifikation von Stentprothesen im Falle von dringlichen Indikationen, mit allerdings unklarem unmittelbaren Zeitvorteil und mittel-und langfristigen Stellenwert gegenüber einem OR[6,33, 34].▪ Gefahr der Intervallruptur: Große und langstreckige Pathologien werden bei einem endovaskulären Vorgehen zur spinalen Protektion meistens 2-3-zeitig versorgt, um das individuelle Patientenrisiko zu minimieren (z. B.…”

Follow-up Results of Endovascular Aneurysm Repair Following Abdominal Visceral Debranching

“…Conventional open surgical repair of thoracoabdominal aneurysms has high mortality and morbidity rates despite advances in surgical field. Morbidities include paraplegia, stroke, and visceral, intestinal, and renal ischemia, as well as dialysis requirement due to renal failure, mostly as a result of distal aortic ischemia [ 5 ] .…”

“…The hybrid procedure was described first by Quinones-Baldrich et al in 1999. The aim of this procedure was to avoid aortic cross-clamping, thoracotomy, single-lung ventilation requirement, and prolonged ischemia of lower half of the body [ 5 ] . Hybrid repair is mainly preferred in patients with comorbidities such as older age, congestive heart failure, decreased pulmonary capacity, and renal pathologies [ 5 ] , or for patients with history of previous surgery [ 7 ] .…”

Open repair of extent-III thoracoabdominal aortic aneurysm using a modified branch-first technique

“…Numerous strategies have been described over the last 50 years, including deep hypothermic circulatory arrest, 1 left heart bypass or full CPB, 2 special spinal protection techniques, and hybrid surgical techniques. 3 The branch-first technique for TAAA repair was originally described by Matalanis and Ch'ng, 4 where the visceral debranching is performed first with a trifurcation graft, which is perfused by attaching an aortic cannula to one of its branches, and finally implanting onto the aortic graft. In principle, this technique provides uninterrupted visceral blood flow during the debranching phase until it is time to perform the graft-to-aorta anastomosis, when perfusion to viscera ceases.…”