Hybrid treatment of thoracoabdominal aortic aneurysm: case series and review of the literature

Petar Zlatanovic; Igor  Končar; Miroslav  Marković; Ranko  Trailović; Vladimir  Cvetić; Lazar  Davidović

doi:10.2298/VSP180606189Z

Petar Zlatanovic Clinical Center of Serbia, Clinic for Vascular and Endovascular Surgery
Igor Končar Clinical Center of Serbia, Clinic for Vascular and Endovascular Surgery, Belgrade, Serbia
Miroslav Marković Clinical Center of Serbia, Clinic for Vascular and Endovascular Surgery, Belgrade, Serbia; University of Belgrade, Faculty of Medicine, Belgrade, Serbia
Ranko Trailović Clinical Center of Serbia, Clinic for Vascular and Endovascular Surgery, Belgrade, Serbia
Vladimir Cvetić Clinical Center of Serbia, Clinic for Vascular and Endovascular Surgery, Belgrade, Serbia
Lazar Davidović Clinical Center of Serbia, Clinic for Vascular and Endovascular Surgery, Belgrade, Serbia

DOI: https://doi.org/10.2298/VSP180606189Z

Keywords: aortic aneurysm, thoracic, blood vessel prosthesis, vascular surgical procedures, endovascular procedures, treatment outcome

Abstract

Abstract

Background/Aim. Open thoracoabdominal aortic aneurysm (ThAAAs) repair is a challenging mission. Total endovascular approach is performed at selected institutions in developing countries, however these are not generalizable. Hybrid procedures offer an alternative approach. The aim of this study was to present our results of the ThAAA hybrid treatment and a literature review. Methods. This is a retrospective study of all patients that underwent the hybrid ThAAA repair at our institution between January 2011 and January 2018. Hybrid ThAAA repair was done as a two-staged procedure – open visceral debranching followed by stent-graft placement (TEVAR). The following data from eligible studies were extracted and analyzed: first author, publication year, patient sample, 30-day/in-hospital mortality, permanent paraplegia rate, presence of endoleaks and graft patency after the follow-up period, overall survival and mean follow-up period. Results. Seven patients underwent the hybrid ThAAA repair at our institution. Neither intraoperative death nor technical failure due to TEVAR was observed. Mean follow-up rate after discharge was 51.71 months [95% confidence interval (CI): 14.67–88.74 months]. At the time of the follow-up, all bypasses were patent and no prosthesis migration was documented. After one year, a case of type Ib endoleak was identified and treated successfully. Twenty-five studies were eligible for the literature review. Primary technical success was 91.69% (95% CI: 85.34–97.24%). Mean percentage of permanent paraplegia was 5.27% (95% CI: 3.55–7.01%). Visceral graft patency during the mean follow-up of 27.54 months (95% CI: 17.41–37.66 months) was 94.5% (95% CI: 92.5–96.5%). Mean pooled percentage rate of overall endoleaks during the follow-up period was 16.72% (95% CI: 11.15–22.29%). Analysis revealed 15.32% (95% CI: 11.04–19.61%) of 30-day/in-hospital mortality and 65.98% (95% CI: 58.15–73.81%) of overall survival after the follow-up period. Conclusion. Although thought as less invasive, the hybrid ThAAA repair is still associated with a considerable morbidity and mortality.

References

REFERENCES

Lemaire SA, Price MD, Green SY, Zarda S, Coselli JS. Results of open thoracoabdominal aortic aneurysm repair. Ann Cardio-thorac Surg 2012; 1(3): 286–92.

Estrera AL, Sheinbaum R, Miller CC, Harrison R, Safi HJ. Neu-romonitor-guided repair of thoracoabdominal aortic aneu-rysms. J Thorac Cardiovasc Surg. 2010; 140(6 Suppl): S131– 5; discussion S142‒6.

Bensley RP, Curran T, Hurks R, Lo RC, Wyers MC, Hamdan AD, et al. Open repair of intact thoracoabdominal aortic aneurysms in the American College of Surgeons National Surgical Quality Improvement Program. J Vasc Surg 2010; 58(4): 894‒900.

Reilly LM, Rapp JH, Grenon SM, Hiramoto JS, Sobel J, Chuter TA. Efficacy and durability of endovascular thoracoabdominal aortic aneurysm repair using the caudally directed cuff technique. J Vasc Surg 2012; 56(1): 53– 63; dis-cussion 63‒4.

Guillou M, Bianchini A, Sobocinski J, Maurel B, D'elia P, Tyrrell M, et al. Endovascular treatment of thoracoabdominal aortic aneurysms. J Vasc Surg 2012; 56(1): 65–73.

Greenberg R, Eagleton M, Mastracci T. Branched endografts for thoracoabdominal aneurysms. J Thorac Cardiovasc Surg 2010; 140(6 Suppl): S171‒8.

Zhou W, Reardon M, Peden EK, Lin PH, Lumsden AB. Hybrid approach to complex thoracic aortic aneurysms in high-risk patients: Surgical challenges and clinical outcomes. J Vasc Surg 2006; 44(4): 688–93.

Black SA, Wolfe JHN, Clark M, Hamady M, Cheshire NJ, Jenkins MP. Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization. J Vasc Surg 2006; 43(6):1081‒9; discussion 1089.

Lee WA, Brown MP, Martin TD, Seeger JM, Huber TS. Early re-sults after staged hybrid repair of thoracoabdominal aortic an-eurysms. J Am Coll Surg 2007; 205(3): 420–31.

Van de Mortel RHW, Vahl AC, Balm R, Buth J, Hamming JF, Schurink GW, et al. Collective experience with hybrid proce-dures for suprarenal and thoracoabdominal aneurysms. Vascu-lar 2008; 16(3): 140–6.

Quinones-Baldrich W, Jimenez JC, DeRubertis B, Moore WS. Combined endovascular and surgical approach (CESA) to thoracoabdominal aortic pathology: A 10- year experience. J Vasc Surg 2009; 49(5): 1125–34.

Donas KP, Lachat M, Rancic Z, Oberkofler C, Pfammatter T, Guber I, et al. Early and midterm outcome of a novel technique to simplify the hybrid procedures in the treatment of thoracoabdominal and pararenal aortic aneurysms. J Vasc Surg. 2009; 50: 1280–4.

Drinkwater SL, Böckler D, Eckstein H, Cheshire NJ, Kotelis D, Wolf O, et al. The visceral hybrid repair of thoraco-abdominal aortic aneurysms--a collaborative approach. Eur J Vasc Endovasc Surg 2009; 38(5):578–85.

Patel R, Conrad MF, Paruchuri V, Kwolek CJ, Chung TK, Cambria RP. Thoracoabdominal aneurysm repair: Hybrid versus open repair. J Vasc Surg. 2009; 50(1): 15–22.

Chiesa R, Tshomba Y, Melissano G, Logaldo D. Is hybrid proce-dure the best treatment option for thoraco-abdominal aortic aneurysms? Eur J Vasc Endovasc Surg 2009; 38(1): 26‒34.

Kabbani LS, Criado E, Upchurch GR, Patel HJ, Eliason JL, Rectenwald J, et al. Hybrid repair of aortic aneurysms involving the visceral and renal vessels. Ann Vasc Surg 2010; 24(2): 219–24.

Patel HJ, Upchurch GR, Eliason JL, Criado E, Rectenwald J, Wil-liams DM, et al. Hybrid debranching with endovascular repair for thoracoabdominal aneurysms: A Comparison with open repair. Ann Thorac Surg 2010; 89(5): 1475–81.

Kuratani T, Kato M, Shirakawa Y, Shimamura K, Sawa Y. Long-term results of hybrid endovascular repair for thoraco- ab-dominal aortic aneurysms. Eur J Cardiothorac Surg 2010; 38(3): 299–304.

Smith TA, Gatens S, Andres M, Modrall JG, Clagett GP, Arko FR. Hybrid repair of thoracoabdominal aortic aneurysms involving the visceral vessels: comparative analysis between number of vessels reconstructed, conduit, and gender. Ann Vasc Surg. 2011; 25(1): 64–70.

Hughes GC, Andersen ND, Hanna JM, McCann RL. Thoracoab-dominal aortic aneurysm: hybrid repair outcomes. Ann Cardiothorac Surg 2012; 1(3): 311–9.

Tshomba Y, Melissano G, Logaldo D, Rinaldi E, Bertoglio L, Civilini E, et al. Clinical outcomes of hybrid repair for thoracoabdominal aortic aneurysms. Ann Cardiothorac Surg 2012; 1(3): 293–303.

Bianchini Massoni C, Geisbüsch P, Gallitto E, Hakimi M, Gargiulo M, Böckler D. Follow- up outcomes of hybrid procedures for thoracoabdominal aortic pathologies with special focus on graft patency and late mortality. J Vasc Surg 2014; 59(5): 1265–73.

Chiesa R, Tshomba Y, Logaldo D, Kahlberg A, Baccellieri D, Apruzzi L. Possible graft-related complications in visceral debranching for hybrid B dissection repair. Ann Cardiothorac Surg 2014; 3(4): 393‒9.

Rosset E, Ben Ahmed S, Galvaing G, Favre JP, Sessa C, Ler-musiaux P, et al. Editor’s Choice- Hybrid treatment of thoracic, thoracoabdominal, and abdominal aortic aneurysms: A multicenter retrospective study. Eur J Vasc Endovasc Surg 2014; 47(5): 470–8.

Gkremoutis A, Schmandra T, Meyn M, Schmitz-Rixen T, Keese M. Hybrid approach to emergent and urgent treatment of com-plex thoracoabdominal aortic pathology. Eur J Vasc Endovasc Surg 2014; 48(4): 407‒13.

Benrashid E, Wang H, Andersen ND, Keenan JE, McCann RL, Hughes GC. Complementary roles of open and hybrid ap-proaches to thoracoabdominal aortic aneurysm repair. J Vasc Surg 2016; 64(5): 1228‒38.

Jain A, Flohr TF, Johnston WF, Tracci MC, Cherry KJ, Upchurch GR Jr, et al. Staged hybrid repair of extensive thoracoabdomi-nal aortic aneurysms secondary to chronic aortic dissection. J Vasc Surg 2016; 63(1): 62‒9.

Hawkins RB, Mehaffey JH, Narahari AK, Jain A, Ghanta RK, Kron IL, et al. Improved outcomes and value in staged hybrid extent II thoracoabdominal aortic aneurysm repair. J Vasc Surg 2017; 66(5): 1357‒63.

van de Graaf RA, Grune F, Hoeks SE, Ten Raa S, Stolker RJ, Verhagen HJ, et al. One-Year Follow-Up After Hybrid Thora-coabdominal Aortic Repair. Vasc Endovascular Surg 2017; 51(1): 23‒7.

Tsilimparis N, Debus SE, Biehl M, Spanos K, Larena-Avellaneda A, Wipper S, et al. Fenestrated-branched endografts and visceral debranching plus stenting (hybrid) for complex aortic aneurysm repair. J Vasc Surg 2018; 67(6): 1684‒9.

Shuto T, Wada T, Miyamoto S, Kamei N, Hongo N, Mori H. Ten-year experience of the thoraco-abdominal aortic aneurysm treatment using a hybrid thoracic endovascular aortic repair. Interact Cardiovasc Thorac Surg 2018; 26(6): 951‒6.

Davidović L, Ilić N, Končar I, Dimić A, Čolić M, Sindjelić R. Hybrid procedure in the treatment of thoracoabdominal aortic aneurysms: case report. Srp Arh Celok Lek 2013; 141(1‒2): 89‒94. (Serbian)

Canaud L, Karthikesalingam A, Jackson D, Cresswell L, Cliff M, Markar SS, et al. Clinical outcomes of single versus staged hy-brid repair for thoracoabdominal aortic aneurysm. J Vasc Surg 2013; 58: 1192–200.

Rigberg DA, McGory ML, Zingmond DS, Maggard MA, Agustin M, Lawrence PF, et al. Thirty-day mortality statistics underestimate the risk of repair of thoracoabdominal aortic aneurysms: a statewide experience. J Vasc Surg 2006; 43(2): 217‒22; discussion 223.

Moulakakis KG, Mylonas SN, Antonopoulos CN, Liapis CD. Combined open and endovascular treatment of thoracoab-dominal aortic pathologies: a systematic review and meta-analysis. Ann Cardiothorac Surg 2012; 1(3): 267–76.

Oderich GS, Timaran C, Farber M, , Quinones-Baldrich W, Escobar G, Gloviczki P et al. RR14. Spinal cord injury after hybrid en-dovascular repair of thoracoabdominal aortic aneurysms in the North American Complex Abdominal Aortic Debranching (NACAAD) Registry. J Vasc Surg 2012; 5(6 Suppl): 93S‒4S.

Lin PH, Kougias P, Bechara CF, Weakley SM, Bakaeen FG, Le-maire SA, et al. Clinical outcome of staged versus combined treatment approach of hybrid repair of thoracoabdominal aor-tic aneurysm with visceral vessel debranching and aortic endo-graft exclusion. Perspect Vasc Surg Endovasc Ther 2012; 24(1): 5‒13.

Davidović L, Marković M, Sindjelić R, Savić N, Kostić D, Cinara I, et al. Early results in the surgical treatment of Crawford type IV thoracoabdominal aneurysms. Acta Chir Iugosl 2005; 52(3): 49‒54. (Serbian)

Davidović LB. Surgical treatment of thoracoabdominal aortic aneurysms. Srp Arh Celok Lek 2006; 134 Suppl 1: 17‒26. (Serbian)

Davidovic LB, Ilic N, Koncar I, Dragas M, Markovic M, Sindjelic R, et al. Some technical considerations of open thoracoabdominal aortic aneurysm repair in a transition country. Vascular 2011; 19(6): 333‒7.

Koncar IB, Colic M, Davidovic LB, Sindelic RB, Ilic N, Dragas M. Ruptured thoracoabdominal aneurysm with aortocaval fistula, aortic dissection type III, and bilateral femoral aneurysms in patient with Marfan syndrome. Am Surg 2010; 76(6): 657‒9.