Complementary roles of open and hybrid approaches to thoracoabdominal aortic aneurysm repair

Abstract

Objective Thoracoabdominal aortic aneurysm (TAAA) repair remains a significant challenge with considerable perioperative morbidity and mortality. A hybrid approach visceral debranching with endovascular aneurysm exclusion has been used to treat high-risk patients and therefore to 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.

Hybrid Repair of Thoracoabdominal Aortic Aneurysm with Rerouting of Visceral Arteries

“…A limitation of hybrid TAAA repair involves endoleaks probably secondary to aortic remodeling over time and long-segment endografts implanted for aneurysm exclusion [40]. In scientific literature, the incidence of endoleaks is variable in different series (Table 21.1) but is a matter of concern because it may expose patients to future reintervention and may leave them at risk of aneurysm rupture.…”

Debranching aortic surgery

“…In a recent report comparing 84 conventional open and 81 hybrid repairs, despite the greater comorbidity burden in the hybrid group, with a significantly higher rate of preoperative chronic renal failure (a well-known independent predictor of mortality), there were no differences in the in-hospital mortality or spinal cord ischemia rates, while patients in the conventional group presented more strokes (9.5% vs. 0%, P=0.017) and those in the hybrid group a significantly increased rate of definitive dialysis (14.8% vs. 3.6%, P=0.043) and higher reintervention rates (12.3% vs. 1.2%, P=0.004), mainly due to endoleaks. Both groups had equivalent survival rates at the first year (hybrid 69% vs. open 77%) and similar longterm aorta-specific survival, suggesting that both techniques can have complementary roles and that the coexistence of several options for treatment of TAAAs in a single centre allows for the treatment of a greater number of patients (65).…”

Hybrid aortic repair with antegrade supra-aortic and renovisceral debranching from ascending aorta

“…Conventional surgery is still associated with substantial perioperative morbi-mortality rates, especially in the elderly and fragile patients, which are however, the fastest growing segment of the population. A recent report comparing open and hybrid repair for TAAA showed that patients selected for hybrid procedures were significantly older and showed greater comorbidities (12). Despite this fact, there were no significant differences in the in-hospital mortality and postoperative paraplegia rates between the two groups.…”

“…One and five-year survival rates were 69% and 32% respectively, in the hybrid group vs. 77% and 56% in open group. The worse late survival rate appears to be mainly influenced by a higher comorbid disease burden in the hybrid patient group (12). Some authors consider hybrid TAAA repair a procedure with unacceptable morbidity and mortality, suggesting that high-risk patients with TAAA should receive a non-interventional approach (13).…”