Visceral Debranching Research Articles

TOTAL VISCERAL DEBRANCHING IN A PATIENT WITH ATHEROSCLEROTIC THORACOABDOMINAL AORTIC ANEURYSM AND OCCLUSION OF ALL VISCERAL BRANCHES

This article describes the clinical observation of a patient with an atherosclerotic aneurysm of the thoracoabdominal aorta and the occlusion of all visceral arteries. Taking into account the occlusion of all visceral arteries, we opted for a hybrid method of treatment, which included total visceral debranching followed by endoprosthetics of the thoracoabdominal aorta. The chosen method made it possible to execute an open surgery without any complications.

Fenestrated-branched endografts and visceral debranching plus stenting (hybrid) for complex aortic aneurysm repair

ObjectiveThe aim of this study was to assess the immediate postoperative and midterm outcome of complex aortic aneurysm treatment necessitating four-vessel revascularization with either a total endovascular approach (fenestrated-branched stent graft [FBSG]) or a hybrid technique of visceral debranching plus stenting. MethodsThe clinical data of consecutively treated patients presenting with a complex aortic aneurysm that necessitated four-vessel revascularization between 2010 and 2015 were retrospectively analyzed. ResultsThere were 98 patients (65 men [68%]) with a mean age of 70.65 ± 4 years who presented with aortic aneurysm (Crawford type I, 12; type II, 18; type III, 12; type IV, 24; type V, 6; and juxtarenal and suprarenal, 26) and were treated with either FBSG (76/98 [77.5%]) or hybrid repair (22/98 [22.4%]). Twenty-six patients were symptomatic (16, pain; 10, contained rupture). The mean maximum aneurysm diameter was 65 ± 15 mm, and 53% of the patients had a prior aortic intervention. In FBSG-treated patients, 15 off-the-shelf multibranched stent grafts, 3 surgeon-modified fenestrated stent grafts, and 58 custom-made devices tailored to the patient's anatomy were used. Four fenestrations, four branches, and their combination were used in 38 cases, 30 cases, and 8 cases, respectively. A total of 304 target vessels were addressed, with technical success rate of 96% (292/304). In most hybrid cases (18/22 [82%]), a two-stage procedure was undertaken. All target vessels were successfully revascularized with 88 bypasses. The 30-day mortality was 15.3% (15/98), and the early target vessel occlusion was 9.1% (2 in FBSG, 7 in hybrid). After multivariate analysis, type of procedure (hybrid) was independently associated with higher early mortality (odds ratio, 6.3; P = .01). The morbidity was mainly attributed to pulmonary complications (16.3%), lower extremity weakness (16.3%), mesenteric ischemia (6.1%), dialysis on discharge (6.1%), and complete paraplegia (4.3%). Acute renal failure (2.6% vs 18%; P = .03) and mesenteric ischemia (3% vs 23%; P = .001) presented more commonly in the hybrid group. The mean follow-up was 16.4 ± 5 months, and the mortality rate was 19.4% (12% in the FBSG group vs 45% in the hybrid group; P = .05). The graft and stent graft patency rate was 87.8% (three branches and nine bypasses were occluded). ConclusionsFBSG and hybrid technique seem to be feasible treatment options for complex aortic aneurysms that necessitate four-vessel revascularization. FBSG may be associated with lower mortality and morbidity rates in comparison to the hybrid procedure. FBSG should be the treatment of choice for complex aneurysms in patients with comorbidities, whereas hybrid repair should be considered for acute cases unsuitable for endovascular repair.

Postoperative Outcomes of Complex Aortic Aneurysm Repair Using Hybrid Open-Endovascular Techniques

Aortic disease becomes more prevalent with age and can result in acute aortic conditions including aneurysm, dissection, intramural hematoma and penetrating ulcers. Repair techniques for these conditions remain controversial due to the varying outcomes of studies. This retrospective study collected and analyzed data from twenty-three (23) patients with complex aortic aneurysms repaired using hybrid open-endovascular techniques. A high percentage of patients (82.6%) suffered from multiple comorbidities, including hypertension, hyperlipidemia, renal disease, coronary artery disease, congestive heart failure and prior aortic procedures. All patients presented with ASA scores 3 or 4. Eleven patients (47.8%) presented with aneurysms of the ascending, transverse and descending arch, and seven patients (30.4%) with thoracoabdominal aneurysm. 78.3% of patients underwent thoracic vessel debranching, while the remainder underwent visceral vessel debranching (13.0%) or thoracic and visceral debranching (8.7%). No patients suffered visceral ischemia, spinal cord injury, extremity amputation or reoperation for bleeding post-operatively. Two patients suffered minor stroke (8.7%) and one patient (4.3%) had major stroke. Three patients (13.0%) suffered temporary kidney injury and one patient (4.3%) developed renal failure requiring dialysis. Four patients (17.4%) developed Type II stent graft endoleaks. All patients had patent grafts. Reintervention occurred in two patients (8.7%). Thirty-day mortality occurred in three patients (13.0%). These results are within the range reported in other studies involving hybrid repair of aortic conditions, and show that hybrid open-endovascular repair is a feasible alternative in high-risk patients.

Long-term results of endovascular repair for descending thoracic aortic aneurysms

ObjectiveSince thoracic endovascular aortic repair (TEVAR) received U.S. Food and Drug Administration approval for the treatment of descending thoracic aneurysms in March 2005, excellent 30-day and midterm outcomes have been described. However, data on long-term outcomes are lacking with Medicare data suggesting that TEVAR has worse late survival compared with open descending repair. As such, the purpose of this study was to examine the long-term outcomes for on-label use of TEVAR for repair of descending thoracic aneurysms. MethodsOf 579 patients undergoing TEVAR between March 2005 and April 2016 at a single referral center for aortic surgery, 192 (33.2%) were performed for a descending thoracic aneurysm indication in accordance with the device instructions for use, including 106 fusiform (55.2%), 80 saccular (41.7%), and 6 with both saccular and fusiform (3.1%) aneurysms. All aneurysms were located distal to the left subclavian artery and proximal to the celiac axis, and hybrid procedures including arch or visceral debranching were excluded with the exception of left carotid-subclavian artery bypass. Aortic dissection and intramural hematoma as indications for TEVAR were also excluded. Primary 30-day and in-hospital outcomes included mortality, stroke, need for new permanent dialysis, and permanent paraparesis or paraplegia. Primary long-term outcomes included survival and rate of reintervention secondary to endoleak. The Kaplan-Meier method was used to estimate long-term overall and aorta-specific survivals. ResultsThe mean age was 71.1 ± 10.4 years. All aneurysms in this series were degenerative in nature and no patients with a connective tissue disorder were included. The mean aortic diameter was 5.9 ± 1.5 cm at time of intervention. Rates of 30-day and in-hospital mortality, stroke, permanent dialysis, and permanent paraparesis and paraplegia were 4.7%, 2.1%, 0.5%, and 0.5%, respectively. At a mean follow-up of 69 ± 44 months (range, 3-141 months), there were 68 late deaths (35.4%), two of which were due to aortic rupture. Overall and aorta-specific survivals at 141 months (11.8 years) were 45.7% and 96.2%, respectively. Endovascular reintervention was required in 14 patients (7.3%) owing to type I (n = 10), type II (n = 2), and type III (n = 2) endoleak, all of which subsequently resolved. No patient required open reintervention for any cause. ConclusionsLong-term (12-year) aorta-specific survival after on-label endovascular repair of degenerative descending thoracic aneurysms in nonsyndromic patients is excellent (96%) with sustained protection from rupture, and a low rate of reintervention owing to endoleak (7%). Endovascular repair should be considered the treatment of choice for this pathology.

EndoAnchors in Thoracic, Thoracoabdominal, and Complex Abdominal Endovascular Aortic Repairs: Safe and Effective

Thoracic endovascular aortic repair (TEVAR) and complex endovascular abdominal aortic repair (CEVAR) are performed despite anatomic constraints and complicated aortic disease. Using Heli-FX EndoAnchors (Medtronic, Santa Rosa, Calif) for endograft fixation in the infrarenal aorta has been described. This study was performed to assess the applicability and outcomes of EndoAnchors in TEVAR and CEVAR. This was a retrospective review of endovascular aortic repairs performed with EndoAnchors between 2012 and 2016. Primary study end points included freedom from migration and type I endoleak requiring reintervention. A total of 101 patients underwent 54 TEVARs and 47 CEVARs with EndoAnchor; 22 patients (21.8%) were treated for thoracic aortic aneurysm, 35 (34.7%) for thoracoabdominal aneurysm, 22 (21.8%) for pararenal aneurysm, and 22 (21.8%) for infrarenal aneurysms with hostile neck anatomy. There were 45 cases (44.6%) performed as index operations, and 56 (55.4%) were redo operations. TEVAR endografts were deployed in zone 0 or 1 in 40.1% of patients, requiring adjunctive procedures (arch debranching, 20; in situ arch fenestration, 9; supra-aortic trunk chimney, 4; visceral debranching, 2). In CEVAR patients, one visceral vessel was treated in 25 patients (24.8%), two in 6 patients (5.9%), three in 24 patients (23.8%), and four in 5 patients (5.0%). EndoAnchors were placed for therapeutic indications in 41.6% of cases and for prophylactic indications in 58.4%. Technical success of deployment was 99.6%. Mean follow-up was 14.3 ± 11.0 months. At 2 years, freedom from type I endoleak requiring reintervention was 93.8% for thoracic aneurysms, 100% for thoracoabdominal aneurysms, and 94.1% for abdominal aneurysms, with no significant difference in freedom from type I endoleak between redo (93.7%) and index (96.7%) operations (P = .752). EndoAnchors can be safely used in TEVAR and CEVAR and can decrease rates of graft migration and type I endoleak. Additional data and long-term follow-up are needed to further define the use of this technology.

Hybrid Visceral and Renal Debranching Followed by Thoracic Endovascular Repair for Thoracoabdominal Aneurysm

Hybrid repair of thoracoabdominal aortic aneurysms (TAAA) may reduce morbidity and mortality in high-risk candidates, but their utility continues to be debated. We report our experience using a hybrid procedure consisting of open visceral debranching followed by endovascular aortic repair.

Long-Term Results of Endovascular Repair for Descending Thoracic Aortic Aneurysms

Since thoracic endovascular aortic repair (TEVAR) received US Food and Drug Administration approval for the treatment of descending thoracic aneurysms in March 2005, excellent 30-day and midterm outcomes have been described. However, data on long-term outcomes is lacking with Medicare data suggesting that TEVAR has worse late survival compared with open descending repair. As such, the purpose of this study was to examine the long-term outcomes for on-label use of TEVAR for repair of descending thoracic aneurysm. Of 444 patients undergoing TEVAR between March 2005 and April 2016 at a single referral center for aortic surgery, 200 (45.0%) were performed for a descending thoracic aneurysm indication including 113 fusiform (56.5%), 81 saccular (40.5%), and six both saccular and fusiform (3.0%). All aneurysms were located distal to the left common carotid artery and proximal to the celiac axis, and hybrid procedures including arch or visceral debranching were excluded with the exception of left carotid-subclavian artery bypass. Aortic dissection and intramural hematoma as indications for TEVAR were also excluded. Primary 30-day/in-hospital outcomes included mortality, stroke, need for new permanent dialysis, and permanent paraparesis/paraplegia. Primary long-term outcomes included survival and rate of reintervention secondary to endoleak. The Kaplan- Meier method was used to estimate long-term overall and aorta-specific survival. Mean age was 71.0 ± 10.5 years (Table). All aneurysms were degenerative in nature with no patients with a connective tissue disorder. Mean aortic diameter was 5.8 ± 1.5 cm at time of intervention. Thirty-day rates of in-hospital mortality, stroke, permanent dialysis, and permanent paraparesis/paraplegia were 4.5%, 2.0%, 0.5%, and 1.0%, respectively. At a mean follow-up of 35 ± 32 months (range, 1-156 months), there were 61 late deaths (30.5%), two of which were due to aortic rupture. Actuarial overall and aorta-specific 13-year survival were 43.3% and 95.7%, respectively (Fig). Endovascular reintervention was required in 14 patients (6.9%) because of type I (n = 10), type II (n = 2), and type III (n = 2) endoleak, all of which subsequently resolved. Zero patients required open reintervention for any cause. Long-term (13-year) aorta-specific survival following endovascular repair of degenerative descending thoracic aneurysms in nonsyndromic patients is excellent (96%) with a low rate of reintervention due to endoleak (7%), and endovascular repair should be considered the treatment of choice for this pathology.TablePatient and procedural characteristicsDemographicsTotal (N = 200) Age, years71.0 ± 10.5 Male sex55.5% (111) White race72.5% (145) BMI27.9 ± 5.6 ComorbiditiesHypertension91.0% (182)Hyperlipidemia73.5% (147)History of tobacco use68.0% (136)Diabetes mellitus21.0% (42)Coronary artery disease38.0% (76)Congestive heart failure4.0% (8)History of stroke11.0% (22)PAD33.5% (67)COPD33.5% (67)CKD20.5% (41)Connective tissue disorder0.0% (0)Prior aortic surgery40.0% (80)ASA score, median3 (2-4)Case status Elective75.0% (150) Urgent/emergent25.0% (50)Indication for TEVAR DTA, fusiform56.5% (113) DTA, saccular40.5% (81) DTA, fusiform and saccular3.0% (6)Endovascular devices Gore TAG/C-TAG56.0% (112) Medtronic Talent16.0% (32) Cook Zenith10.5% (21) Medtronic Valiant10.0% (20) Cook TX2LP/Alpha Thoracic8.0% (16) Bolton Relay1.5% (3) Medtronic Aneurx0.5% (1)30-day/in-hospital outcomes Mortality4.5% (9) Stroke2.0% (4) New permanent dialysis0.5% (1) Permanent paraparesis/paraplegia0.5% (1)ASA, American Society of Anesthesiologists; BMI, body mass index; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; DTA, descending thoracic aneurysm; TEVAR, thoracic endovascular aortic repair. Open table in a new tab

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

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

IF13. Outcomes of the Candy-Plug Technique to Achieve Thrombosis of Thoracic False-Lumen Postdissection Aneurysms

False lumen (FL) perfusion and aneurysmal degeneration of the thoracic aorta limits the response to endovascular treatment in patients with chronic aortic dissection by retrograde flow arising from distal entry tears. Aim of the study is to evaluate the “candy-plug” FL embolization technique to prevent back-flow in chronic aortic dissection aneurysms. The “candy-plug” stent graft is a custom-made endograft at the shape of a candy with proximal and distal diameters of up to 50 mm that taper down at the middle of the graft to 16 mm (Fig 1). With the adjunct of a regular plug, complete FL occlusion can be achieved. Between 2013 and 2015, 12 patients (11 males; mean age, 65 ± 11years; American Society of Anesthesiologists 3/4) with chronic type B dissection (CTBD) received candy-plug endografts for residual type A aortic dissection (n = 6) or CTBD aneurysms (n = 6) in conjunction with extension of aortic stent grafting of the true lumen (TL) to the celiac trunk. Eleven procedures were elective and one acute. All procedures were technically successful in occluding FL perfusion, and only one patient required additional embolization techniques at the level of the candy-plug (Fig 2). There was no 30-day mortality, but one patient with transient spinal cord injury recovered. At a mean follow-up of 12 ± 6 months (range, 1-26), there were two reinterventions due to persisting retrograde FL perfusion. On later follow-up, one patient underwent visceral debranching and thoracoabdominal stenting. Two further patients required fenestrated endografts of the abdominal aorta for expansion of the abdominal chronic aortic dissection aneurysm. There was only one late death in the patient with conversion to hybrid procedure. FL embolization of chronic dissection aneurysms with a candy-plug endograft presents a useful tool that expands the material options for FL embolization. Application of this technique achieves complete FL thrombosis in most patients, who would otherwise require open surgery or complex endovascular procedures with fenestrated/branched abdominal endografts.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Clinical analysis of hybrid treatment for extensive aortic disease

To evaluate the effect of extensive aortic diseases (EAD) after hybrid repair with supra-arch branches or visceral arterial debranching and endovascular repair. A total of 24 EAD patients (19 male and 5 female) underwent hybrid repair in Department of Vascular Surgery, Zhongshan Hospital, Fudan University between March 2005 and April 2015. The clinical data was analyzed retrospectively. The mean age was (49±12) years (from 29 to 69 years). The high-risk candidates for open surgery were enrolled in the study. The patients, including 14 cases with thoracic aortic aneurysms and 10 cases with aortic dissection, were treated by one or two stages. Post-operative follow-up with CT angiography was performed at 3, 6 and 12 months and then annually thereafter. A total of 74 branches, including 63 with visceral arteries and 11 with supra-arch arteries, were recanalized. Nine patients were treated in two-stage hybrid procedure and fifteen were repaired by one stage. The perioperative mortality was 12.5% (3/24), whereas the aneurysm-related mortality was 8.3% (2/24). The 30-day patency of the grafts was 95.9% (71/74). There was no endoleak, paralysis, and intestinal ischemia at 30 days post-hybrid procedures. Four cases (16.6%) suffered acute renal dysfunction. During the follow-up (3 to 123 months), there were two deaths and one endoleak (type Ia and III) which emerged at 4 months post-procedure. The 1-year and 3-year survival rates were 81.7% and 73.5%, respectively. Hybrid treatment is safe and effective for complex EAD patients in the midterm follow-up. It is especially suitable for the high-risk patients with comorbidities, re-intervention, or little tolerance to open surgery repair.

Results of the Gore Hybrid Vascular Graft in Challenging Aortic Branch Revascularization during Complex Aneurysm Repair

Prolonged organ ischemia during complex aortic surgery is associated with increased morbidity and mortality. A novel hybrid graft (Gore Hybrid Vascular Graft) ascomposite of expanded polytetrafluorethylene vascular prosthesis that has a section reinforced with nitinol was investigated for feasibility and effectiveness during aortic repair. Retrospective analysis of all consecutive patients treated with the hybrid vascular graft (HVG). Indication for graft implantation was surgeon's preference for branch revascularization in challenging aortic repair. Within 26months, 25 Gore HVGs and 17 conventional grafts were implanted in 12 patients (age, 73years; range, 33-79 years, 8 men). Eleven patients were treated for thoracoabdominal aortic aneurysms and one for aortoiliac aneurysm (elective=6, urgent=6). Nine visceral debranching procedures, 2 Crawford procedures, and 1 repair of an internal iliac aneurysm were performed. The distribution of HVG use was left renal artery=10, right renal artery=9, superior mesenteric artery=4, celiac trunk=1, and internal iliac artery=1. Time to restore visceral blood flow during visceral debranching was 7±4min for the Gore HVG vs. 12 ± 6min for conventional grafts (P<0.01).Technical success was achieved in all cases. At 12months of median follow-up, cumulative patency of the HVGs was 96%. The Gore HVG offers a new, simplified, and time-sparing technique for visceral anastomoses during complex aneurysm repair. However, long-term results are still lacking and need to be awaited.

FT3. Visceral Debranching and Stenting (Hybrid) vs Fenestrated-Branched Stent Grafts (FBSG) in High-Risk Patients With Thoracoabdominal Aortic Aneurysms

High-risk patients with thoracoabdominal aortic aneurysms (TAAAs) can be managed either with fenestrated-branched stentgrafts (FBSG) or with visceral debranching and stenting (hybrid). This was a retrospective single-center study comparing consecutive patients with TAAA undergoing hybrid vs FBSG procedure with four-vessel revascularization. While in our institution FBSG has become the standard of care in high-risk patients during the study period, and selected subgroups of patients with connective tissue, anatomy unsuitable for custom-made FBSG, or urgent cases unsuitable for off-the-shelf devices are managed by the hybrid procedure. Thirty-two patients underwent four-vessel FBSG (72 years, 72% female), and 20 patients underwent four-vessel hybrid (68 years, 66% female). Patients treated with hybrid had more frequently connective tissue disorders (CTD; 25% vs 3%, P < .05) and previous aortic repair (80% vs 41%, P < .05). The maximum TAAA diameter was larger, but not statistically significant, in patients treated with hybrid (mean 68 mm vs 61 mm, P = NS), and patients treated with hybrid presented more frequently as symptomatic (25% vs 6%) or contained ruptures (15% vs 3%). Early mortality was significantly higher in the hybrid vs the FBSG group (35% vs 3%). Similarly, severe pulmonary complications requiring tracheotomy (10% vs 0%), stroke (10% vs 0%), acute renal failure requiring temporary dialysis (10% vs 3%), and mesenteric ischemia (25% vs 0%) were more frequent in the hybrid group. On the other hand, lower extremity weakness occurred more frequently in the FBSG group (22% vs 5%). At a survivors' mean follow-up of 14 and 18 months, respectively, late deaths occurred in 15% in the hybrid and in 3% in the FBSG group. Hybrid was independently associated with higher early mortality compared with FBSG, even after controlling for urgent cases and CTD. FBSGs were associated with lower mortality and morbidity compared with the hybrid procedure. FBSG should be considered the treatment of choice for high-risk patients with TAAA. Hybrid should remain in the vascular armentarium for selected subgroups of patients unsuitable for endovascular repair.

A new technique for intra-abdominal arteries revascularization via extra-anatomic bypass from the brachiocephalic artery with a videoscopic retrosternal tunnel

Extra-anatomic revascularizations of intra-abdominal or lower limbs arteries, or both, are indicated (1) when the aorta is unsuitable for anatomic bypasses, (2) in patients unfit for aortic surgery, (3) for graft infections, and (4) for visceral debranching during hybrid treatment of a thoracoabdominal aneurysm. We describe a new extra-anatomic bypass from the brachiocephalic artery with video-guided retrosternal tunneling. We discuss the advantages and drawbacks of this technique.

Visceral Debranching for the Treatment of Thoracoabdominal Aortic Aneurysms: Based on a Presentation at the 2013 VEITH Symposium, November 19-23, 2013 (New York, NY, USA).

Surgical repair of thoracoabdominal aortic aneurysms (TAAA) is associated with significant morbidity and mortality. Hybrid approaches that involve visceral debranching and aortic endografting allow for an alternative approach in certain high-risk patients. In most circumstances the visceral vessels can be bypassed in a retrograde manner from the iliac arteries via a midline laparotomy, and the aortic aneurysm subsequently excluded with standard aortic endografts. These procedures avoid the extensive two-cavity exposure, aortic cross-clamping, and mechanical circulatory support that comprise open TAAA repair, and offer the theoretical advantage of being less invasive. Despite this, outcomes have been mixed with reported perioperative mortality rates of 0% and 34% and permanent paraplegia rates of 0% to 13% in most major series. The reported outcomes, as well as the variation between centers, highlight the importance of patient selection in undertaking hybrid repair. In practice, the best outcomes are achieved in patients who have high-risk anatomy, rather than high-risk comorbidities.

The assessment of collateral communication after hybrid repair for Crawford extent II thoraco-abdominal aortic aneurysms.

The repair of extensive thoraco-abdominal aortic aneurysms (TAAAs) is invasive and carries a high risk for spinal cord injury (SCI). The aim of this study was to assess the early results and collateral circulation to the spinal cord after hybrid repair for Crawford extent II aortic aneurysms. Between 1997 and 2013, we performed 128 thoracic endovascular aortic repair (TEVAR) procedures for TAAAs. This study reviews 12 patients who underwent hybrid TEVAR for a Crawford extent II aortic aneurysm (mean age: 56 years, 6 men, chronic dissection: 10). Aortic arch repair was performed to create a proximal landing zone and visceral debranching bypass was performed to create a distal landing zone at separate stages prior to TEVAR. Subsequently, a stent graft was deployed to cover the residual downstream aorta. TEVAR was generally performed the day after the final debranching procedure. Cerebrospinal fluid drainage was performed, and the mean blood pressure was maintained at >90 mmHg in all cases. The median operation time for TEVAR was 94 min (range: 71-421 min) and the mean blood loss was 300 ml (range: 130-1350 ml). No SCI or in-hospital death was observed after TEVAR. Multidetector computed tomography identified three arteries (subclavian artery, external iliac artery and internal iliac artery) providing collateral circulation to spinal segmental arteries (SAs). In all cases, mid-thoracic SAs (Th5-8) and low lumbar SAs (L2-5) were fed by the subclavian artery and the internal iliac artery, respectively. Additionally, low thoracic to high lumbar SAs (Th9-L1) communicated with the subclavian artery via the lateral thoracic wall and/or the external iliac artery via the abdominal wall. We achieved satisfactory early and mid-term outcomes with hybrid repair for Crawford extent II TAAAs. Furthermore, collateral circulation to SAs was maintained during and after TEVAR regardless of the extent of the aortic repair.

Propensity Adjusted Analysis of Open and Endovascular Thoracic Aortic Repair for Chronic Type B Dissection: A Twenty-Year Evaluation

Optimal treatment of chronic type B aortic dissection (CBAD), whether open (open descending aortic repair, OAR) or endovascular (thoracic endovascular aortic repair, TEVAR), is controversial, suggesting a comparative analysis is warranted. One hundred twenty-two of 1,049 patients (1993 to 2013) undergoing descending aortic repair required intervention for CBAD 29.2 ± 34.9 months after the initial acute event and formed the study cohort (mean age 59.7 years). Those with degenerated residual type A dissection were excluded (n= 65). Eighty-eight had extent IIIB CBAD; 11 had intramural hematoma. Indications for surgery included aneurysmal degeneration (n= 105), rupture (n= 8), acute or chronic dissection (n= 8), and extension of dissection (n= 1). Open strategy included descending (n= 71) and thoracoabdominal repair (n=19), with hypothermic circulatory arrest used in 70 patients. The TEVAR was performed with (n= 2) or without (n= 30) visceral debranching. A treatment strategy propensity score incorporating time since initial acute event, CBAD extent, year of intervention, age, and selected comorbidities was constructed for multivariable analysis. Early outcome included the following: 30-day mortality 4% (n= 5); stroke 2% (n= 2); permanent paraplegia 3% (n= 4); renal failure requiring dialysis 7% (n= 8, 5 temporary and 3 permanent); and tracheostomy 3% (n= 4). Visceral aorta intervention (odds ratio [OR] 3.5, p= 0.026) and maximum aortic diameter (OR 1.1, p= 0.001) but not treatment type (p= 0.64) independently predicted an early composite outcome comprised of these variables. Ten-year survival was 56.2%. Baseline creatinine (hazard ratio [HR] 1.7, p < 0.001) and peripheral vascular disease (HR 2.5, p= 0.021), but not treatment type (p= 0.225) predicted late mortality. Ten-year freedom from aortic rupture or need for reintervention was 78.3%. Treatment efficacy was improved after OAR (3-year freedom 96.7% vs TEVAR 87.5%, p= 0.026), and this was confirmed after Cox regression (TEVAR, HR 4.6, p= 0.046). Intervention for CBAD can be performed with excellent results, either by an open or endovascular approach. The higher rate of treatment failure after TEVAR warrants modification of current device design or endovascular approach before broad application of this treatment strategy.

Possible graft-related complications in visceral debranching for hybrid B dissection repair.

Hybrid repair (HR) of thoracoabdominal aortic aneurysm (TAAA) and dissection (TAAD), consisting of rerouting renovisceral branches followed by endograft aortic repair, has been shown to be a feasible option. It is especially appealing in patients unfit for both open and total endovascular repair. In order to determine the role of dissecting etiology and intraoperative variables as risk factors for graft-related complications in visceral debranching, we retrospectively analyzed the clinical outcomes, patency rate and hemodynamic alterations of the renovisceral debranching grafts in our series. We analyzed 55 consecutive patients who underwent thoracoabdominal aortic HR between 2001 and 2013 in our center. Forty-four procedures were performed for TAAA and 11 procedures for TAAD. In TAAD patients, dissection involved 9/44 (20.5%) renovisceral vessels. One hundred and fifty-nine visceral bypasses were made (156 retrograde; three anterograde). Thirty-day mortality was 12.7% (n=7). Potential graft-related complications included four cases of pancreatitis (7.3%) and five of peri-operative renal failure (9.1%). At a mean follow-up of 36.1 months, the global rate of visceral graft occlusion was 9.4% (15/159), leading to fatal bowel infarction in two patients and kidney loss in seven patients. Actuarial primary patency in renovisceral grafts at 12, 24, and 36 months was 96.3%, 92.6%, and 90.2% respectively. At the level of the anastomosis of the graft to the superior mesenteric artery, significant flow alterations (systolic peak velocity >250 cm/s) were observed during computed flow dynamics analysis in 18.5% of cases. Overall, an additional procedure to ensure patency was required in 19 bypasses intraoperatively and three during follow-up. The presence of aortic dissection had no significant impact on debranching graft-related complications. During multivariate analysis, retropancreatic routing to CT was the only independent predictor of graft-related complications (P=0.006). Specific visceral graft-related complications were not uncommon in our series and were often associated with clinical consequences. Hemodynamic alterations of debranching grafts were observed in particular at the level of the anastomosis with the superior mesenteric artery. Careful follow-up is mandatory in order to monitor visceral bypasses and facilitate patency when required.

RR1. A Propensity Adjusted Analysis of Open and Endovascular Thoracic Aortic Repair for Chronic Type B Dissection: A 20-Year Evaluation

Background. Optimal treatment of chronic type B aortic dissection (CBAD), whether open (open descending aortic repair, OAR) or endovascular (thoracic endovascular aortic repair, TEVAR), is controversial, suggesting a comparative analysis is warranted. Methods. One hundred twenty-two of 1,049 patients (1993 to 2013) undergoing descending aortic repair required intervention for CBAD 29.2 ± 34.9 months after the initial acute event and formed the study cohort (mean age 59.7 years). Those with degenerated residual type A dissection were excluded (n[ 65). Eighty-eight had extent IIIB CBAD; 11 had intramural hematoma. Indications for surgery included aneurysmal degeneration (n [ 105), rupture (n [ 8), acute or chronic dissection (n [ 8), and extension of dissection (n [ 1). Open strategy included descending (n [ 71) and thoracoabdominal repair (n [ 19), with hypothermic circulatory arrest used in 70 patients. The TEVAR was performed with (n [ 2) or without (n [ 30) visceral debranching. A treatment strategy propensity score incorporating time since initial acute event, CBAD extent, year of intervention, age, and selected comorbidities was constructed for multivariable analysis. Results. Early outcome included the following: 30-day mortality 4% (n [ 5); stroke 2% (n [ 2); permanent

Hybrid multistep approach to mega-aortic syndrome: the Lupiae technique

Several techniques have been described for the treatment of thoraco-abdominal aneurysms in patients with mega-aortic syndrome (MAS), but the incidence of stroke, spinal cord injury and endoleaks remains significant. We present the mid-term results of a new hybrid, multistep technique to treat patients with MAS. From November 2005 to November 2012, 118 patients with MAS underwent surgical repair of thoracic and thoraco-abdominal aneurysms with the Lupiae technique. Fifty-five patients presented chronic aneurysms and 63 patients Type A acute dissections. Eighty-three patients underwent ascending aorta and arch replacement with a multibranched Dacron graft and epiaortic vessels rerouting (thoracic Lupiae procedure). Twenty patients had the thoracic Lupiae procedure plus partial visceral debranching (coeliac trunk and superior mesenteric artery [SMA]) through an upper mini-laparotomy. Fifteen patients had the thoracic Lupiae procedure plus a complete visceral debranching (coeliac trunk, SMA and renal arteries) using a second multibranched Dacron graft to replace the infrarenal aorta. All the patients with chronic aneurysms and 34 of 63 patients with Type A dissections underwent implant of endovascular stent grafts. In-hospital mortality was 8.4%. No patients had stroke or spinal cord injury. The incidence of temporary renal failure was 5.2%. No patients presented endoleaks immediately and at follow-up CT scans. No death or reoperation occurred during the follow-up. These results evidence that the Lupiae technique is a safe and effective option for the treatment of patients with MAS, achieving the complete exclusion of thoraco-abdominal aneurysms and of the residual false lumen in patients with acute aortic dissections.

A Novel Hybrid Approach Using Antegrade Visceral Debranching from Both Axillary Arteries for Thoracoabdominal Aneurysm Repair

Hybrid aortic surgery combining visceral debranching and stent grafting is an alternative to conventional open surgery and branched stent grafting for thoracoabdominal aneurysm repair. Visceral aortic branch bypasses are usually performed from the iliac arteries or the infrarenal or ascending aorta. Herein, we describe a new debranching technique to treat a painful Crawford type III thoracoabdominal aneurysm in a high-risk patient who was deemed unsuitable for open, endovascular, or traditional hybrid repair. The superior mesenteric artery and the right renal arteries were exposed via a right retroperitoneal approach and revascularized from the right axillary artery. Splenic and left renal arteries were exposed via a left retroperitoneal approach and revascularized from the left axillary artery.