Combined Open and Endovascular Treatment of Thoracoabdominal Aneurysms and Secondary Expanding Aortic Dissections: Early and Mid-Term Results From a Single-Center Series

Article Outline

• Abstract
• Introduction
• Methods
  • Patients
  • Planning of the Procedure
  • Surgical Procedures
  • Follow-up
• Results
  • Technical Success
  • The 30-Day Mortality
  • Morbidity
    • Paraplegia/paraparesis
    • Other major complications
  • Endoleak and Graft Patency
  • Follow-up
• Discussion
• Conclusion
• References
• Copyright

Background

We present a review of our experience with combined surgical therapy with endovascular stent repair and conventional revascularization of the supraaortic and/or visceral/renal arteries (hybrid procedure) in the treatment of thoracoabdominal aortic aneurysms and dissections.

Methods

We followed 20 patients (7 women, median age 58.3 years, age range 37-68 years) prospectively. Severe comorbidity was present in 7 patients, 13 patients had previous aortic surgery. The median diameter of the thoracoabdominal aneurysm was 74.4 mm (Crawford I, 1 patient; II, 11; III, 7; V, 1), and 13 patients had previous aortic surgery. After visceral and renal revascularization, three stent grafts were implanted on average. Follow-up examination was every 6 months. The median follow-up was 174.5 days (15-375 days).

Results

The 30-day mortality was 10% and the neurological complication rate was 10% with incomplete paraparesis in 2 patients. Computed tomography scanning revealed six endoleaks in 5 patients (Type Ia, 3 patients; Ib, 1; II, 1; III, 1) and four visceral graft occlusions in 4 patients (right renal artery, 2 patients; left renal artery, 2). Endoleaks (Ia, Ib, and III) were surgically revised. During follow-up, 3 patients died. The remaining patients recovered to full activity. A significant aneurysm shrinkage was found in 5 patients. Two patients developed secondary endoleaks.

Conclusion

Our results show that hybrid procedure might be an alternative to conventional thoracoabdominal repair of the aorta, especially in high-risk patients.

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Introduction 

The natural course of a thoracoabdominal aneurysm (TAAA) is fatal with a 2-year mortality rate of up to 76%, whereas after surgery this rate decreases to 30%.¹, ² However, open repair of TAAAs is associated with a mortality rate of 20% in National Data Sets³, ⁴, ⁵, ⁶ and 4%-16% at specialized centers.⁶, ⁷, ⁸, ⁹, ¹⁰, ¹¹, ¹², ¹³ Severe complications include paraplegia (1%-15%), acute renal failure (2.3%-12.7%), and severe cardiopulmonary complications (4.4%-33%).⁵, ⁶ Increased morbidity is associated with severe pulmonary disease (up to 40%) and renal impairment (up to 30%). Severe renal, cardiac, or pulmonary comorbidity; Crawford extent Type II TAAA; and redo surgery are especially associated with a higher mortality risk and a higher risk for severe complications.⁵, ¹¹, ¹⁴, ¹⁵, ¹⁶

Due to the significant complication rates for open thoracoabdominal repair, aortic endovascular exclusion combined with debranching techniques of the supra-aortic and the visceral/renal arteries may be an alternative for high-risk patients. The hybrid procedure combines open surgical revascularization of the visceral and renal arteries followed by an endovascular exclusion of the aneurysm. Several groups reported cases and smaller series.¹⁷, ¹⁸, ¹⁹, ²⁰, ²¹, ²², ²³, ²⁴, ²⁵, ²⁶, ²⁷, ²⁸, ²⁹, ³⁰, ³¹. So far, three clinical series with 29, 13, and 6 patients have been published,³² with promising results in terms of mortality and paraplegia rates. Results from a larger series from St. Mary´s Hospital containing 29 patients⁵ showed no paraplegia and a 30-day mortality rate of up to 13%. This article reviews our experience with urgent and elective hybrid procedures for TAAAs since 2004.

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Methods 

Patients 

Between November 2004 and May 2007, we followed 20 patients prospectively (7 females, median age 58.3 years, age range 37-68 years) who underwent a hybrid procedure to treat TAAA and secondary expanding dissection (SED). Eighteen patients (TAAA, 8 patients; SED, 10) were treated electively, and 2 patients were admitted with contained ruptures (TAAA, 1 patient; SED, 1). Severe comorbidity was present in 7 of 20 patients (35%). 9 patients had previous thoracic aortic surgery, and 8 patients had previous major abdominal surgery, of whom 4 patients had infrarenal aortic replacement (Table I).

Table I. Demographic and anamnestic data for 20 consecutive patients with hybrid procedure

BMI, body mass index; HAT, hypertension (HAT); DM, diabetes mellitus; HCH, hypercholesterolemia; RI, renal impairment; COPD, chronic obstructive pulmonary disease; CAD, coronary artery disease; ASA, Association of Anaesthesiologists Score; Pre Abd Surg, previous abdominal surgery; Prev Thor Surg, previous thoracic surgery; IRAAA, infrarenal aortic aneurysm repair; AV&R, aortic valve and root replacement; TEVAR, thoracic endovascular aneurysm repair.

The aneurysms were classified according to the modified Crawford classification (Fig. 1).³³ We found Crawford Type I in 1, Type II in 11, Type III in 7, and Type V in 1 patient. The median maximum diameter of the aortic aneurysm was 71.5 mm (50-120 mm) (Table 2). Due to the severe comorbidity, previous aortic surgery, and aneurysm morphology, 75% of the patients of this series were of high risk for surgical repair of their TAAA.

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• Fig. 1 

  Modified Crawford classification of thoracoabdominal aneurysms.

Table II. Morphological data on the aneurysms

Aneurysm type according to the Crawford classification.³³

Planning of the Procedure 

All patients underwent contrast-enhanced multislice computed tomography (CT) scanning performed from the carotid bifurcation to the femoral arteries. If a minimal length of the distal or proximal attachment site of 20 mm was not given, proximal attachment site was optimized by proximal debranching and distal attachment by infrarenal aortic replacement. CT scans and CT reconstructions were used for the stent planning. In the proximal and distal attachment sites, an oversizing of 10%-20% was targeted and an overlap of 5-8 cm between two stents was projected. In case of significant tapering of the attachment sites, the procedure was planned in reversed trombone technique.

Surgical Procedures 

A supra-aortic debranching prior to the visceral hybrid procedure was necessary in 4 of 20 patients; 3 patients received a bypass from the right common carotid artery to the left subclavian artery with an implantation of the left common carotid artery into the graft and ligation of the proximal left common artery and the left subclavian artery proximal of the vertebral artery. One patient received a bypass from the left common carotid artery to the left subclavian artery in the same manner.

The hybrid procedures were performed with the patient under general anesthesia in the supine position. Cell salvage, transfusion, and rapid infusers were used. A median transabdominal approach was used to provide exposure to the abdominal aorta, the celiac artery, the superior mesenteric artery, and both renal arteries. In 7 patients, the infrarenal aorta was replaced by a Dacron graft to create a distal attachment site. The inflow site for retrograde visceral artery grafting was determined for each patient individually according to previous abdominal aortic surgery and the extent of the thoracoabdominal disease. In case of infrarenal aortic replacement by tube interposition, or if no replacement was necessary (14 patients), the bypass grafts were anastomosed in an end-to-side version to both native common iliac arteries. If the infrarenal aorta (6 patients) and iliac arteries were replaced by a bifurcated infrarenal graft, the visceral bypasses were anastomosed in a side-to-end version to the limbs of the prosthesis. The superior mesenteric artery was revascularized in all patients, and the celiac trunk in 17 patients; in 2 patients, revascularization of the celiac trunk was technically impossible because of severe obesity, and in 1 patient, the celiac trunk was occluded.

Revascularization of the renal arteries was not performed bilaterally in 2 patients (TAAA Crawford I, end-stage renal disease [ESRD]); it was performed on the left side, because 1 patient was nephrectomized and the other patient had a nonfunctioning kidney. After cold perfusion of the kidneys, the right renal artery was revascularized in 18 cases and the left renal artery in 16. In the first patients, 2 bifurcated Dacron grafts were used for retrograde visceral grafting. After tunneling one graft through the loose retropancreatic tissue, the anastomosis to the celiac trunk was done in an end-to-side version to maintain splenic blood supply; each other visceral artery was anastomosed in an end-to-end version to the graft branches (8 patients). In the latter patients, a trifurcated Dacron graft was used, and except for one renal artery and the celiac artery, all visceral arteries were grafted in an end-to-end version to the graft. The renal artery was anastomosed in an end-to-side version into one of the graft branches (7 patients). In case three visceral arteries had to be grafted, a bifurcation prosthesis was combined with a Dacron graft (4 patients). If two visceral arteries had to be grafted, one bifurcation graft was used (1 patient). In all cases, the disconnected visceral arteries were ligated close to the aortic origin to prevent Type II endoleak. The immediate graft patency after revascularization was evaluated by flow measurement. All procedures were performed as single-step procedures with endovascular aortic repair after visceral/renal debranching.

After completing visceral and renal bypassing, a suitable access point was chosen for endovascular stent deployment. The stent was placed either through a femoral approach (8 patients) or through a conduit (12 patients) attached to the body of the retrograde graft (8 mm Dacron).To achieve optimal proximal stent positioning and to avoid proximal stent dislocation, the proximal stent was deployed under drug-induced cardiac arrest with adenosine (1 mg/kg body weight). In the case of a significant diameter difference between the proximal and distal attachment sites, the stent grafts were applied in reversed trombone technique starting in the distal attachment site (17 patients), in which case tapered stent grafts were used. A variety of stent grafts were used: in 15 patients, we used Talent^® stent grafts (Medtronic, Santa Rosa, CA, USA); in 2 patients, Zenith^® (Cook, Bloomington, IN, USA); and in 2 patients, Endofit^® (LeMaitre Vascular, Burlington, MA, USA). On average, three (median) stent grafts were used (range 0-6 stent grafts) to exclude the TAAA. The proximal attachment site was distal the brachiocephalic trunk (zone 2) in 3 patients, distal the left common carotid artery (zone 3) in 1 patient, and distal the left subclavian artery (zone 4) in 15 patients. The procedures were completed by angiography to ensure graft patency as well as the absence of endoleaks (Table III).

Table III. Operative details of the conventional part (Conv.), the endovascular part (EV), the revascularized vessels (Revasc.), and postoperative complications for 20 patients after hybrid procedure

IRAAA, infrarenal aortic aneurysm repair; LRA, left renal artery; RRA, right renal artery; SMA, superior mesenteric artery; CT, celiac trunc; SG, stent graft; Prox. LZ, proximal anding zone; type 2, distal brachiocephalic trunk; type 3 distal left common carotid artery; type 4, distal left subclavian artery; prox. debr., proximal debranching; OR time, length of procedure; postop. complications, postoperative complications.

Follow-up 

Follow-up was performed clinically and by CT scan and duplex scans postoperatively and every 6 months after initial surgery.

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Results 

The median hospital stay was 21.3 days (range 11-68 days), and the median intensive care unit stay was 8.1 days (range 2-19.1 days). The median procedure time was 499 minutes (range 250-935 minutes). Median blood loss was 1.9 L (range 0.5-7.0 L).

Technical Success 

The procedure was completed in 19 of the 20 patients. In 1 patient, stent graft deployment was not completed because of impossible deployment in the aortic arch. This patient was rescheduled for stent grafting with a low-profile system due to aneurysm progression. He died on day 353 after visceral debranching, 5 days before readmission, from aneurysm rupture.

The 30-Day Mortality 

The 30-day mortality was 5.5% (1 patient) in elective patients and 10% (2 patients) for the entire series. Patient 3 died on day 15 due to multiple system organ failure following colon ischemia and necrotizing pancreatitis. Patient 20 died on day 15 due to multiple system organ failure after the repair of a ruptured TAAA with a hemothorax.

Morbidity 

Permanent paraparesis rate was 10% (2 patients). Both patients had incomplete paresis of the lower extremity. Patient 10 felt weakness in his legs but was able to walk without support. Patient 16 developed complete paralysis of the left leg and weakness of the right leg. Patient 12 showed delayed, transient neurological deficit with complete paraplegia lasting 12 hours, from which the patient recovered from completely (Table III).

Major complications included resection of an ischemic left colon in 1 patient, tracheostomy and prolonged respiratory support in 3 patients, temporary support for renal impairment in 3 patients, temporary inotropic support in 9 patients, and necrotizing pancreatitis in 2 patients.

Endoleak and Graft Patency 

Postoperative multislice CT scan revealed six endoleaks in 5 patients (Type Ia, 3 patients; Type Ib, 1; Type II, 1; Type III, 1) and four visceral graft occlusions in 4 patients (right renal artery, 2 patients; left renal artery, 2). Except for one Type Ia endoleak, all Type Ia, Type Ib, and Type III endoleaks were surgically corrected. The occlusions of the renal grafts did not result in renal failure but rather in compensated and reversible elevation of the serum creatinine level (Table IV).

Table IV. Endoleaks and graft occlusions for 20 patients after hybrid procedure detected by postoperative multislice CT scan

AGP, all grafts patent.

Follow-up 

Average follow-up time was 174.5 days (range 15-375 days). During follow-up, 3 patients died; one patient sustained an aneurysm-related death. In detail, patient 6 died on day 60 due to pneumonia, patient 13 died on day 353 due to rupture of his aneurysm, and patient 10 died on day 167 as a result of pulmonary insufficiency. All the other patients of the series recovered to full activity and without signs of organ failure. Patient 8 showed a secondary proximal endoleak due to distal stent dislocation, which could be treated by proximal stent extension after proximal debranching. Patient 2 developed a type 3 endoleak, which was treated by stent grafting. Follow-up CT scans revealed a shrinkage of the aneurysm in 9 of the 20 patients; in 5 of the 20 patients, the shrinkage was 10 mm or more compared to the postoperative CT scans (Table V).

Table V. Maximum aneurysm diameter preoperatively, during follow-up, and diameter difference (mm) measured by axial CT scan in the 20 patients of the series

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Discussion 

This report concerns our experience with a prospective series of 20 patients who underwent the hybrid procedure. Overall, 30-day mortality rate was 10% in all cases and 5.5% in nonruptured cases. This is less than the mortality rate published for open surgery by the national database⁴, ⁵, ⁶ and comparable to the results of specialized centers.⁷, ⁸ Our results are encouraging considering that the patient group was high risk for open surgery regarding serious comorbidity, previous aortic surgery, and aneurysm morphology. All these factors are known as independent risk factors regarding morbidity after open surgery of TAAA.¹¹, ¹⁴, ¹⁵, ¹⁶

Our results underline the findings of Black et al.,⁵ who showed in a comparable publication a mortality rate of 10% in elective and urgent patients. In contrast to the working group of the St. Mary´s hospital⁵ and another working group in Cologne,⁶ whose patients had no paraplegia, the paraparesis rate in our series was 10%. Spinal drainage might have improved our results regarding paraplegia. Two of three patients in our series developed spinal cord ischemia in the state of low arterial blood pressure. As in the early postoperative state, low systolic blood pressure is known as a strong independent risk factor for paraplegia;³⁴ a careful monitoring of a prompt correction of blood pressure is indicated.

After infrarenal aortic repair, the risk for spinal cord ischemia seems to be elevated.³⁴ Surprisingly, none of our affected patients had infrarenal aortic repair, but in both patients with persistent and in the one patient with transient spinal cord ischemia, proximal debranching procedures were performed prior to hybrid procedure. Even as we could confirm the anterograde perfusion of the left vertebral artery by angiography in all cases, proximal debranching might alter the collateral blood flow of the left vertebral artery after proximal debranching and enhance spinal cord ischemia. All three patients with spinal cord ischemia had immediate correction of the blood pressure and steroid therapy.³⁴, ³⁵, ³⁶

In contrast to open surgery, endoleaks are a matter of concern after hybrid procedure. In total, we found 8 endoleaks in 7 patients (35%). This is comparable to the endoleak rate of Black et al. Our endoleak rate for Type I was 20%. Because Type I endoleaks are known to preserve the rupture risk of TAAA, we treated all Type I endoleaks aggressively with success. These results are controversial to the findings of Tse et al.³⁷ and Black et al.,⁵ where some of the Type I proximal endoleaks persisted after proximal stent extension and proximal debranching. A higher endoleak rate for proximal Type I endoleaks was potentially avoided by proximal debranching prior to the hybrid procedure.

In our series, we applied three stent grafts on average (Fig. 2). For that reason, a Type III endoleak may be a potential risk factor in this complex procedure. In our series, we had one Type III endoleak in a patient after the repair, or a Type I TAAA with three stents applied in reversed trombone technique between the first and the second stent graft. This could be treated successfully by repeat stent grafting (Fig. 3). The reversed trombone technique is an effective method for stent grafting in patients with a significant mismatch of the diameter of the proximal and distal attachment sites. We performed retrograde repair using tapered stent grafts in 15 of our patients. In the hybrid procedure, retrograde alloplastic visceral and renal bypassing is necessary. No data exist about the durability and safety of that feature. Some information is provided from a couple of case studies, where patency rates as high as 90%-95% at 36 months were reported.³⁸, ³⁹, ⁴⁰

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• Fig. 2 

  A, B Anterior and posterior views of the preoperative reconstruction (multislice CT scan) of the aorta with a thoracoabdominal aneurysm Type II. C, D Postoperative reconstruction of the CT scan showing a sufficient revascularization of the celiac trunk, superior mesenteric artery, and both renal arteries by two bifurcated grafts originating from the iliac arteries. Exclusion of the thoracoabdominal aneurysm by three stent grafts. E, F Follow-up CT scan (243 days postoperatively) of the descending thoracic aorta with significant shrinkage of the aneurysm sack compared to the CT scan 5 days after the procedure.

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• Fig. 3 

  A, B Type III endoleak between the first and second stent grafts in patient 2. C, D Exclusion of type III endoleak between the first and second stent grafts by repeat stent grafting (patient 2).

We tried to achieve revascularization of the superior mesenteric artery and celiac trunk in all cases because patients with isolated bypassing of the superior mesenteric artery are at unknown and unnecessary risk for severe visceral ischemia in case of graft occlusion to the superior mesenteric artery. In that specific case, the patent graft to the celiac trunk might avoid fatal acute visceral ischemia.⁵ In any case, revascularization of the celiac trunk in 2 patients could not be achieved due to severe obesity (body mass index >29 kg/m²). Furthermore, we had early graft occlusions in 4 patients: 2 grafts to the right renal artery and 2 grafts to the left renal artery occluded within 36 hours after the procedure. As there were no signs of worsening of the renal function, patients were treated conservatively. During follow-up, all grafts remained patent. The durability of the stent grafts, especially when several stents are applied, is still unclear. In our follow-up, 2 of 20 patients showed secondary endoleaks, which were, however, treated successfully. Regarding our median follow-up time of 174.5 days, a significant shrinkage of the aneurysm was found in 5 of the 20 patients.

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Conclusion 

Our results show that hybrid procedure might be an alternative to the conventional thoracoabdominal replacement of the aorta, especially in high-risk patients. Nevertheless, relevant mortality and morbidity rates are still present due to the extent of the procedure and the risk profile of the patients. Further studies are necessary to more precisely define morphological and clinical criteria that qualify patients for hybrid procedure, rather than for conventional repair. As long-term results are anticipated, the conventional thoracoabdominal repair of TAAA remains the gold standard.

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