Thoracic endovascular repair first for extensive aortic disease: the staged hybrid approach

Abstract

OBJECTIVES: Repair of extensive aortic disease carries a significant risk of death and morbidity, the most feared complication being spinal cord ischaemia. Objectives of this study are to characterize patients, describe repair methods and assess feasibility and safety of hybrid staged repair for treatment of extensive aortic disease. METHODS:From to 2001 to 2013, 22 patients underwent extensive aortic repair that included a thoracic endovascular aortic repair (TEVAR) first followed by an open completion repair extending through the visceral and infrarenal aorta for degenerative aneurysm and dissection. At the time of initial repair, all patients were deemed to be at a high risk for conventional open repair and had extensive disease. Indications for open completion included emergency failure of TEVAR (n = 3), early two-stage approach (n = 6) and delayed disease progression after TEVAR (n = 13). The median interval between stages was 6.5 months. The mean age was 56 ± 14 years, 5 patients had connective tissue disorder and the mean maximum aortic diameter was 58 ± 16 mm preoperatively. RESULTS:There was no death or major complication after initial TEVAR, but the operative mortality rate was 9% (n = 2) after the open procedure. One of these patients died from intraoperative myocardial infarction during emergency repair, and the other had disseminated intravascular coagulation during delayed repair for disease progression after TEVAR. Other complications included paralysis in 1 (4.5%), tracheostomy in 2 (9%) and dialysis in 1 (4.5%), and there was 1 reoperation for bleeding (4.5%). The median follow-up was 37 (range 3.3-93) months and there were no late deaths. There were four late reoperations for proximal disease progression leading to Type 1 endoleak (n = 2), Type A dissection (n = 1) and root aneurysm (n = 1). CONCLUSIONS:Use of a TEVAR-first approach in combination with a staged open repair is a safe and feasible treatment strategy for repair of extensive aortic disease. A staged hybrid approach to aortic repair in patients at high risk for total aortic replacement may limit morbidity.

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

“…Other limited reports of staged hybrid repair indicate similar renal failure rates as reported in this single center study. 18 Despite higher rates of AKI, detailed analysis reveals low incidence of progression to renal failure. These results suggest selective renal perfusion is effective and staged hybrid repair does not increase the risk for renal failure.…”

“…Additionally, others have reported no deaths or major adverse events associated with initial TEVAR prior to distal repair. 18 Finally, value would ideally be assessed in a risk-adjusted manner such as has been previously done in the cardiothoracic surgery literature. 24 Robust risk models are unfortunately unavailable although baseline assessment of patients demonstrated similar comorbidities and risk factors.…”

“…Newer evidence suggests that staged hybrid repair can supplement these techniques to further reduce morbidity. 12-18 The results suggest that thoracic endovascular repair followed by open distal repair is a safe and reasonable repair strategy. However, there is limited evidence regarding outcomes compared to open repair.…”

Open aortic surgery after thoracic endovascular aortic repair

“…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).…”

“…One caveat of these findings is that the patients in this cohort were atypically young (mid-50s), as compared with patients who typically undergo TAAA repair (mid-60s). Similarly, Vivacqua and colleagues [44] at the Cleveland Clinic have described their experience with a staged hybrid approach of TEVAR followed by open extent III TAAA repair, in which the endograft is fully salvaged (n = 22). Most of these repairs were performed to treat progression of aortic disease after TEVAR (n = 13) in patients with chronic dissection (n = 16).…”