Results with an algorithmic approach to hybrid repair of the aortic arch

Abstract

Objective Hybrid repair of the transverse aortic arch may allow for aortic arch repair with reduced morbidity in patients who are suboptimal candidates for conventional open surgery. Here, we present our results with an algorithmic approach to hybrid arch repair, based upon the extent of aortic disease and patient comorbidities. Methods Between August 2005 and January 2012, 87 patients underwent hybrid arch repair by three principal procedures: zone 1 endograft coverage with extra-anatomic left carotid revascularization (zone 1, n=19), zone 0 endograft coverage with aortic arch debranching (zone 0, n=48), or total arch replacement with staged stented elephant trunk completion (stented elephant trunk, n=20). Results The mean patient age was 64 years and the mean expected in-hospital mortality rate was 16.3% as calculated by the EuroSCORE II. 22% (n=19) of operations were non-elective. Sternotomy, cardiopulmonary bypass, and deep hypothermic circulatory arrest were required in 78% (n=68), 45% (n=39), and 31% (n=27) of patients, respectively, to allow for total arch replacement, arch debranching, or other concomitant cardiac procedures, including ascending ± hemi-arch replacement in 17% (n=8) of patients undergoing zone 0 repair. All stented elephant trunk procedures (n=20) and 19% (n=9) of zone 0 procedures were staged, with 41% (n=12) of patients undergoing staged repair during a single hospitalization. The 30-day/in-hospital rates of stroke and permanent paraplegia/paraparesis were 4.6% (n=4) and 1.2% (n=1), respectively. Three of 27 (11.1%) patients with native ascending aorta zone 0 proximal landing zone experienced retrograde type A dissection following endograft placement. The overall in-hospital mortality rate was 5.7% (n=5), however, 30-day/in-hospital mortality increased to 14.9% (n=13) due to eight 30-day out-of-hospital deaths. Native ascending aorta zone 0 endograft placement was found to be the only univariate predictor of 30-day/in-hospital mortality (odds ratio, 4.63; 95% confidence interval, 1.35-15.89; P=0.02). Over a mean follow-up of 28.5 ± 22.2 months, 13% (n=11) of patients required reintervention for type 1A (n=4), type 2 (n=6), or type 3 (n=1) endoleak. Kaplan-Meier estimates of survival at 1, 3, and 5 years were 73%, 60%, and 51%, respectivel. Conclusions Hybrid aortic arch repair can be tailored to patient anatomy and comorbid status to allow complete repair of aortic pathology, frequently in a single stage, with acceptable outcomes. However, endograft placement in the native ascending aorta is associated with high rates of retrograde type A dissection and 30-day/in-hospital mortality and should be approached with caution.

Mid-term Results of Chimney and Periscope Grafts in Supra-aortic Branches in High Risk Patients

“…The high risk profile for conventional surgery (graft replacement) with a Euroscore II >5% and/or presenting multifocal aneurysm locations was defined according to Andersen et al, including comorbidities (age >65 years, coronary artery disease, heart failure, chronic obstructive disease, and impaired renal function) and anatomical characteristics (thoraco-sternotomy incision and two stage open repair). 3 At the study institution there is a policy for high risk patients unfit for conventional surgery with a life expectancy more than 2 years. In younger/fitter patients, SAB rerouting in association with standard TEVAR is the preferred choice.…”

Open repair techniques in the aortic arch are still superior

“…Between August 2005 and January 2012, among a cohort of 87 patients undergoing hybrid procedures of various types, 48 patients underwent hybrid arch repair with zone 0 endograft landing zone and aortic arch debranching (62).…”

Infected Aortic Aneurysms

“…Although controversial, the artery of Adamkiewicz, normally located between T8 and L2, should be preserved if possible [100]. If essential branches of the aorta are to be covered by stent grafts, revascularization by either a bypass surgery, open debranching, or endovascular debranching with a chimney technique or a fenestrated stent graft is necessary [101][102][103][104][105]. Adjunctive procedures, such as open debridement and percutaneous drainage, could be performed, based on the clinical judgment [74].…”