Hybrid Repair of Extensive Thoracoabdominal Aortic Disease Results in Similar Operative Outcomes When Performed for Distal Aortic Degeneration on Surveillance Compared to Initial Staged, PlannedStrategy
Michelle Moe-Aiken, Quang Le, Behzad S Farivar, Martha L Weaver, John A Kern, Margaret C Tracci, William D Clouse
University of Virginia, Charlottesville, VA
Background: Repair of extensive thoracoabdominal aortic aneurysms (TAAA) carries significant risk. Hybrid repair incorporating TEVAR followed by distal open repair as a strategy to reduce open repair to type IV extent has been described. Our group has observed thoracic aortic remodeling and health care value with hybrid repair. This strategy may also be used with proximal treatment and monitoring of distal aortic disease not requiring treatment at initial operation. Yet, reports of operative results remain sparse. The purpose of this study is to further describe operative results of hybrid repair and compare those undergoing planned, staged extensive repair versus those undergoing TEVAR with later distal degeneration requiring hybrid completion. Methods: Between March 2007-May 2022, 60 patients underwent extensive TAAA hybrid repair. Patient demographics, comorbidities, previous aortic intervention, aortic pathology, operative details, interval between procedures, in-hospital morbidity, and mortality were obtained. Major adverse events are defined as death, spinal cord ischemia (SCI), and new dialysis requirement. Results: Of these 60 cases, 73.3% (n=44) were performed for aortic dissection (AD) with aneurysmal degeneration, and 26.7% (n=16) were indicated for aneurysmal degeneration alone. Mean age of dissection patients was 52.73 ±15.33 years and 69.06 ± 5.38 (p=0.0001) years in those with degenerative aneurysms. Hybrid repair was done in a planned, staged fashion in 51.7% (n=31) and as a result of surveillance of distal aortic growth in 48.3% (n=29). Mean interval between TEVAR and distal aortic repair was 4.1 ±5.2 months for staged, planned patients. As expected, this was longer in those with surveillance, completion repair (23.9 ±27.6 months; p=0.0001). Women accounted for 48% of planned, staged patients but only 24% of surveillance, completion patients (p=.05). Largest aortic diameters repaired were 64 ± 7.6 mm in AD and 63 ± 10.0 mm in degenerative aneurysms. Prior ascending and arch repair was common (45% surveillance vs. 32% planned; p=.32), and arch debranching operations preceding TEVAR were performed in 10.3% and 6.5% of cases, respectively (p=.59). AD pathology was more common in surveillance, completion patients compared to staged, planned (93% vs. 55%; p=.001) and initial extent II disease was present more often in those undergoing staged, planned operations (100% vs. 83%; p=.03). There were no differences in preoperative co-morbidities between groups including diagnosis of connective tissue disease. There were no mortalities or SCI after initial TEVAR with 2 surveilled, completion patients with new dialysis requirements (p=0.14). After subsequent open repair, overall, in-hospital mortality occurred in 7 patients [11.7%; 2 surveilled (7%): 5 staged, planned (16%); p=.27] and SCI in 12 [20%; 4 surveilled (13.8%): 8 staged, planned (25.8%); p=.25]. New dialysis requirements were observed in 4 surveilled (14%) and 4 (13%) staged, planned patients (p=0.92). Reoperation for any indication occurred in 5 surveillance patients (17%) and 5 (16%) staged, planned (p=.91). Overall, major adverse events were no different between groups [n=7 (24.1%) surveilled, completion; n=9 (29.0%) staged, planned; p=.668]. Conclusions: Open completion repair after TEVAR with anastomosis to the endograft based on surveillance results in similar operative outcomes compared to a staged, planned approach. Even with the hybrid approach, open TAAA repair morbidity and mortality after preceding TEVAR remains significant. This may be due to the selection of patients with complex anatomy, such as AD, for this strategy. Further investigation of durability and care implications using hybrid repair are warranted as endovascular care evolves.
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