Thoracoabdominal aortic aneurysm: hybrid repair outcomes

Abstract

Background: Thoracoabdominal aortic aneurysms (TAAA) remain amongst the most formidable of surgical challenges, particularly degenerative aneurysms in the elderly population with concomitant pulmonary disease. This report presents an update of our robust single-institution experience with "hybrid" TAAA repair including complete visceral debranching and endovascular aneurysm exclusion in high-risk patients.

Methods: Between March 2005 and June 2012, 58 patients underwent extra-anatomic debranching of all visceral vessels followed by aneurysm exclusion via endovascular means at a single institution. The median number of visceral vessels bypassed was 4. The debranching and endovascular portions of the procedure were performed as a single stage in the initial 33 patients and as a staged approach in the most recent n=25 cases.

Results: Median patient age was 69.0 years; 50% were female. All had significant co-morbidity and were considered suboptimal candidates for conventional open surgical repair. Mean aortic diameter was 6.7¡À1.2 cm. Thirty-day/in-hospital rates of death, stroke, and permanent paraparesis/paraplegia were 9%, 0%, and 4%, respectively; in the most recent 25 patients undergoing staged repair these rates were 4%, 0%, and 0%. Over a mean follow-up of 26¡À21 months, visceral graft patency is 95.3%; all occluded limbs were to renal vessels and none resulted in permanent dialysis. Two patients (3%) have required re-intervention, one for type Ib and one for type III endoleak. Five-year freedom from re-intervention was 94%. Kaplan-Meier overall survival was 78% at 1 year and 62% at 5 years, with a 5-year aorta-specific survival of 87%.

Conclusions: These updated results continue to support hybrid TAAA repair via complete visceral debranching and endovascular aneurysm exclusion as a good option for elderly high-risk patients less suited to conventional open repair. A staged approach to debranching and endovascular aneurysm exclusion appears to yield optimal results.

Keywords: Thoracoabdominal aortic aneurysms (TAAA); endovascular aneurysm; pulmonary disease.

Figure 1

Custom-designed multibranch Dacron graft used for visceral debranching during hybrid thoracoabdominal aortic aneurysm repair

Figure 2

A. Follow-up computed tomographic angiography (CTA) of a patient undergoing hybrid extent II TAAA repair demonstrating widely patent 4-vessel visceral debranching graft and thoracic endografts extending from just distal to the bovine trunk/left common carotid artery down to the aortic bifurcation. The left subclavian artery has been covered and a patent left common carotid to left subclavian artery bypass is seen (arrow); B. Detailed view of abdominal portion of CTA from the same patient demonstrating origin of 4-vessel visceral debranching graft from left common iliac artery with patent graft limbs to the left renal artery (L renal a.), celiac axis, superior mesenteric artery (SMA), and right renal artery (R renal a.). The stump of the antegrade conduit limb used for endograft introduction at the second stage endovascular portion of the repair is likewise indicated. The small arrow denotes one of the multiple radiographic markers on the debranching graft which identify the origins of the various limbs under fluoroscopy.

Figure 3

Kaplan-Meier freedom from re-intervention after hybrid thoracoabdominal aortic aneurysm repair

Figure 4

Kaplan-Meier overall and aorta-specific survival after hybrid thoracoabdominal aortic aneurysm repair

Figure 5

Kaplan-Meier overall survival after hybrid thoracoabdominal aortic aneurysm repair stratified by single versus two-stage procedure