Hybrid aortic procedures for endoluminal arch replacement in thoracic aneurysms and type B dissections

• Published in: Journal of cardiovascular surgery Vol. 47; no. 5; pp. 509 - 517
• Main Authors: Schumacher, H, Von Tengg-Kobligk, H, Ostovic, M, Henninger, V, Ockert, S, Böckler, D, Allenberg, J R
• Format: Journal Article
• Language: English
• Published: Italy Edizioni Minerva Medica 01.10.2006
• Subjects: Aneurysm, Dissecting - classification; Aneurysm, Dissecting - diagnostic imaging; Aneurysm, Dissecting - surgery; Aortic Aneurysm, Thoracic - classification; Aortic Aneurysm, Thoracic - diagnostic imaging; Aortic Aneurysm, Thoracic - surgery; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation - methods; Humans; Prosthesis Design; Severity of Illness Index; Tomography, X-Ray Computed; Treatment Outcome
• ISSN: 0021-9509

The aim of this study was to report our clinical experience with and review current literature on endoluminal aortic hybrid techniques and to evaluate outcome in high-risk patients treated for complex aortic arch lesions combining conventional supra-aortic debranching bypasses with subsequent or staged thoracic endovascular grafting. Of 172 patients treated with thoracic endografts for different thoracic aortic pathologies within the last 8 years, the mid-aortic arch was involved in 25, i.e. at least the left common carotid artery had to be overstented and revascularized to provide a proper proximal landing zone. These debranching bypasses were performed as a simultaneous or a staged procedure. All patients were at high-risk and were excluded by cardiac surgeons as ineligible for conventional arch repair. After partial (n=16) or complete (n=9) supra-aortic transposition, 4 different commercially available endografts (80% TAG, WL Gore) were implanted transfemorally or via iliac conduit. Deployment success was 100% in 25 patients after simultaneous or staged supra-aortic transposition; in 32% an emergency procedure was performed due to contained rupture; in 36% more than 1 endograft system was implanted (2 in 20%, 3 in 8% und 4 in 8%). The overall perioperative thirty-day mortality was 5 of 25 (20%) due to interoperative proximal bare stent perforation (n=1), transfusion related acute lung injury (TRALI n=1), cardiac failure (n=1), embolic stroke (n=1) and pneumonia (n=1). The mean follow-up was 21 months. All endoleaks type I (n=3) were corrected with another endograft; the 2 endoleaks type II sealed spontaneously. The major adverse events were: prolonged ventilation in 5 (20%), temporary renal insufficiency with hemodialysis (n=2), bypass infection (n=1), without any complications (n=9). No cases of paraplegia were recorded. Hybrid aortic arch repair is technically challenging but feasible. This novel approach may be an alternative to standard open procedures in high-risk patients and emergency cases. However, the promising early results need to be confirmed by longer follow-up and larger series.