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 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.

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.

Fig 1

Institutional algorithm for hybrid thoracoabdominal aortic aneurysm (TAAA) repair. These criteria are relative factors in the decision-making process and are not absolute indications or contraindications. The decision for open vs hybrid TAAA repair should be made by a joint vascular and cardiac surgical team with expertise in both techniques. Institutional results with each approach should further influence the decision-making process.

Fig 2

Kaplan-Meier freedom from reintervention after hybrid vs open thoracoabdominal aortic aneurysm (TAAA) repair. Freedom from reintervention was significantly greater after open repair (P = .01).

Fig 3

Kaplan-Meier unadjusted overall survival by procedure type. Unadjusted long-term survival was significantly lower (P = .03) after hybrid vs open thoracoabdominal aortic aneurysm (TAAA) repair.

Fig 4

Aorta-specific survival by procedure type. On long-term follow-up, there was no difference in aorta-specific survival between hybrid and open thoracoabdominal aortic aneurysm (TAAA) repairs (P = .23).

Fig 5

Institutional procedural volumes by year for open thoracoabdominal aortic aneurysm repair (OTAAAR) and hybrid thoracoabdominal aortic aneurysm repair (HTAAAR) demonstrating a shift from a hybrid-predominant to an open-predominant strategy in the latter years of the series.