Staged hybrid repair of extensive thoracoabdominal aortic aneurysms secondary to chronic aortic dissection

Jain, Amit; Flohr, Tanya F.; Johnston, William F.; Tracci, Margaret C.; Cherry, Kenneth J.; Upchurch, Gilbert R.; Kern, John A.; Ghanta, Ravi K.

doi:10.1016/j.jvs.2015.08.060

Cited by 35 publications

(34 citation statements)

References 24 publications

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“…The methodology has been previously described in detail with 18 of the 113 patients included in prior reports. 14, 15 Briefly, TEVAR was performed with stent graft placement from the left subclavian artery to just above the celiac artery. Left carotid-subclavian artery bypass was performed at the discretion of the surgeon, but typically prior to any planned coverage of the left subclavian artery by the TEVAR.…”

Section: Methodsmentioning

confidence: 99%

Improved outcomes and value in staged hybrid extent II thoracoabdominal aortic aneurysm repair

Hawkins

Mehaffey

Narahari

et al. 2017

Journal of Vascular Surgery

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Objective Complex Crawford extent II thoracoabdominal aortic aneurysms (TAAA) can be treated in a hybrid manner with proximal thoracic endovascular aneurysm repair, followed by staged distal open thoracoabdominal repair. The purpose of this study was to evaluate the outcomes and healthcare associated value of this new method compared to traditional open repair over 10 years. Methods A prospectively collected database was used to identify all patients with extent II TAAA undergoing repair at a single institution between 2005 and 2015. Patient characteristics, post-operative outcomes, and incidence of major adverse events (MAE = renal failure, spinal cord ischemia, death) were compared. After adjusting for time since surgery, value was analyzed looking at quality (1/MAE) divided by cost (total health system cost). This is multiplied by a constant to set the value of open TAAA repair to 100. Results A total of 113 consecutive patients underwent extent II TAAA repairs, of which 25 (22.1%) had a staged hybrid approach with a median of 129 days between procedures. No baseline differences in demographic or comorbidity variables existed between groups (p>0.05). The hybrid group had shorter operative time (255 vs 306 minutes; p=0.01), shorter postoperative length of stay (LOS) (10.1 vs 13.3 days; p=0.02), as well as reduced blood loss (1300 vs 2600 mL; p=0.01) at the time of open operation. Despite higher rates of acute kidney injury in the hybrid group (76.0%vs 51.1%, p=0.03) there was no difference in renal failure (8.0% vs 4.5%, p=0.84) The incidence of MAE was lower in the staged hybrid group (20.0% vs 48.9%; p=0.01), without a difference in hospital mortality (4.0 vs 3.4%, p=0.89). Median total cost was higher in the hybrid group ($112,920 vs $72,037, p=0.003). Value was improved in the hybrid group by 56% using mean cost and 178% by median cost. Conclusions The 20% major adverse event rate associated with staged hybrid repair of extent II TAAA was significantly decreased compared to open repair, with a relative reduction of over 50%. Despite higher total hospital costs, staged hybrid repair had 56% to 178% higher healthcare related value compared to standard open repair. In an era of increasing focus on costs and quality, staged hybrid repair of extensive TAAAs is associated with fewer complications than open TAAA repair resulting in a good value investment from a resource utilization perspective.

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Section: Methodsmentioning

confidence: 99%

Improved outcomes and value in staged hybrid extent II thoracoabdominal aortic aneurysm repair

Hawkins

Mehaffey

Narahari

et al. 2017

Journal of Vascular Surgery

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“…2,3 According to the literature, traditional surgical operations include ligation of the LSA, reconstruction of the LSA and LCA, and elective debranching before TEVAR. 4,5 These approaches are complicated and require prolonged operation time. The procedures are also difficult and can increase morbidity and mortality with a combined stroke and death.…”

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confidence: 99%

In Situ Laser Fenestration Is a Feasible Method for Revascularization of Aortic Arch During Thoracic Endovascular Aortic Repair

Qin

Zhao

Wang

et al. 2017

JAHA

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BackgroundReconstruction of the aortic major branches during thoracic endovascular aortic repair is complicated because of the complex anatomic configuration and variation of the aortic arch. In situ laser fenestration has shown great potential for the revascularization of aortic branches. This study aims to evaluate the feasibility, effectiveness, and safety of in situ laser fenestration on the three branches of the aortic arch during thoracic endovascular aortic repair.Methods and ResultsBefore clinical application, the polytetrafluoroethylene and Dacron grafts were fenestrated by an 810‐nm laser system ex vivo, which did not damage the bare metal portion of the endografts and created a clean fenestration while maintaining the integrity of the endografts. In vivo, 6 anesthetized female swine survived after this operation, including stent‐graft implantation in the aortic arches, laser fenestration, and conduit implantation through the innominate arteries and the left carotid arteries. Based on the animal experiments, in situ laser fenestration during thoracic endovascular aortic repair was successively performed on 24 patients (aged 33–86 years) with aortic artery diseases (dissection type A: n=4, type B: n=7, aneurysm: n=2, mural thrombus: n=7). Fenestration of 3 aortic branches was performed in 2 (8.3%) patients. Both the left carotid artery and the left subclavian artery were fenestrated in 6 (25%) patients. Only left subclavian artery fenestration surgery was done in 16 (66.7%) patients. Among these patients, 1 fenestration was abandoned secondary to an acute takeoff of the innominate artery in a type III aortic arch. The average operative time was 137±15 minutes. The technical success rate was 95.8% (n=23). No fenestration‐related complications or neurological morbidity occurred after this operation. During a mean postoperative 10‐month follow‐up (range: 2–17 months), 1 patient died of severe pneumonia, and all the left subclavian artery and carotid artery stents were patent with no fenestration‐related endoleaks upon computed tomography angiography images.ConclusionsIn situ laser fenestration is a feasible, effective, rapid, repeatable, and safe option for the reconstruction of aortic arch during thoracic endovascular aortic repair, which might be available to revascularize the 3 branches. However, follow‐up periods should be extended to evaluate the robustness of this technique.

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“…Full-salvage repairs may be described in the literature as staged hybrid extensive thoracoabdominal aortic repairs [14,[44][45][46]. This terminology is typically used to describe endovascular repair of the descending thoracic aorta (stage 1) followed by open repair of the thoracoabdominal aorta (stage 2).…”

Section: Full Salvage Of the Stent-graftmentioning

confidence: 99%

“…The overriding premise for performing thoracoabdominal aortic repairs in stages is that the collateral circulation [47] of the spinal cord may increase during the interval between repairs and reduce the risk of developing postoperative paraplegia. Jain et al [45] described their experience with a limited number (n = 19) of staged hybrid repair cases. In these cases, TEVAR was used to treat a DTA in patients with acute dissection.…”

Section: Full Salvage Of the Stent-graftmentioning

confidence: 99%

Open aortic surgery after thoracic endovascular aortic repair

Coselli

Spiliotopoulos

Preventza

et al. 2016

Gen Thorac Cardiovasc Surg

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In the last decade, thoracic endovascular aortic aneurysm repair (TEVAR) has emerged as an appealing alternative to the traditional open aortic aneurysm repair. This is largely due to generally improved early outcomes associated with TEVAR, including lower perioperative mortality and morbidity. However, it is relatively common for patients who undergo TEVAR to need a secondary intervention. In select circumstances, these secondary interventions are performed as an open procedure. Although it is difficult to assess the rate of open repairs after TEVAR, the rates in large series of TEVAR cases (>300) have ranged from 0.4 to 7.9 %. Major complications of TEVAR that typically necessitates open distal aortic repair (i.e., repair of the descending thoracic or thoracoabdominal aorta) include endoleak (especially type I), aortic fistula, endograft infection, device collapse or migration, and continued expansion of the aneurysm sac. Conversion to open repair of the distal aorta may be either elective (as for many endoleaks) or emergent (as for rupture, retrograde complicated dissection, malperfusion, and endograft infection). In addition, in select patients (e.g., those with a chronic aortic dissection), unrepaired sections of the aorta may progressively dilate, resulting in the need for multiple distal aortic repairs. Open repairs after TEVAR can be broadly classified as full extraction, partial extraction, or full salvage of the stent-graft. Although full and partial stent-graft extraction imply failure of TEVAR, such failure is generally absent in cases where the stent-graft can be fully salvaged. We review the literature regarding open repair after TEVAR and highlight operative strategies.

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Staged hybrid repair of extensive thoracoabdominal aortic aneurysms secondary to chronic aortic dissection

Cited by 35 publications

References 24 publications

Improved outcomes and value in staged hybrid extent II thoracoabdominal aortic aneurysm repair

Improved outcomes and value in staged hybrid extent II thoracoabdominal aortic aneurysm repair

In Situ Laser Fenestration Is a Feasible Method for Revascularization of Aortic Arch During Thoracic Endovascular Aortic Repair

Open aortic surgery after thoracic endovascular aortic repair

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