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Endovascular Stenting With Open Surgery for Reconstructions of the Ascending Aorta and the Aortic Arch: A Review of Indications and Results of Hybrid Techniques Muhammad A. Rana, Peter Gloviczki and Gustavo S. Oderich PERSPECT VASC SURG ENDOVASC THER 2012 24: 184 originally published online 14 August 2013 DOI: 10.1177/1531003513497984 The online version of this article can be found at: http://pvs.sagepub.com/content/24/4/184
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PVSXXX10.1177/1531003513497984Perspectives in Vascular Surgery and Endovascular TherapyRana et al
Feature Article
Endovascular Stenting With Open Surgery for Reconstructions of the Ascending Aorta and the Aortic Arch: A Review of Indications and Results of Hybrid Techniques
Perspectives in Vascular Surgery and Endovascular Therapy 24(4) 184–192 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1531003513497984 pvs.sagepub.com
Muhammad A. Rana, MD1, Peter Gloviczki, MD1, and Gustavo S. Oderich, MD1
Abstract Hybrid approaches for repair of aneurysms involving the ascending aorta and the aortic arch have been developed to avoid or reduce duration of cardiopulmonary bypass and circulatory arrest and to decrease operative time, blood loss, hospital stay, morbidity, and mortality. These include ascending aorta–based debranching or cervical extraanatomical bypasses followed by stent-grafting. In patients with associated descending aortic aneurysms, the elephant trunk technique is used followed by stent-grafting of the descending thoracic aorta. A review of the literature of hybrid aortic arch reconstructions, published over past 7 years, reveals perioperative mortalities from 0% to 13%, stroke from 0% to 10%, and spinal cord injury in 0% to 13%. The outcomes are comparable to contemporary results from total open and total endovascular reconstructions in spite of the fact that the hybrid approach is generally taken in patients with high surgical risk for open repair and with prohibitive anatomy for total endovascular repair. Keywords hybrid, aortic arch, frozen elephant trunk, elephant trunk, debranching, arch debranching, aortic arch aneurysms, thoracic aortic aneurysms
Background The incidence of thoracic aortic aneurysms (TAAs) is reported to be more than 10 per 100 000 person-years (5.9% in the early 1980s) and has almost doubled over the past 2 decades.1-3 This carries an overall risk of rupture of about 20% after 5 years, which is 31% for aneurysms with a diameter of 6 cm or larger.1,4 Dake and his colleagues’ report of the first endovascular repair of a TAA in 1994 was a major milestone in the management of this disease.5 The US Food and Drug Administration approved thoracic aortic stent-grafting for aneurysmal disease in April 2005. Stent-grafting has been mainly limited to the unbranched segment of the aorta between the left subclavian and the celiac arteries. Recently, however, branched and fenestrated stent-grafts have been used to successfully treat aneurysms involving the arch vessels or the visceral aorta, with some investigators calling it the best option for treating the para-visceral segment.5-8 Acceptable results have also been reported after total endovascular repair of infected thoracic aorta.9 With the surge of endovascular repair for thoracic aortic pathology, the future role of conventional open approaches
to these lesions is being questioned. Total endovascular options at present are limited by the aneurysm anatomy and extent; however, with ongoing advances it has become a matter of controversy whether open or endovascular option will be the best to approach to any TAA. There is a tendency to compare the results of a lesser extent coverage of the aorta with endovascular stent-grafts to more extensive open aortic reconstructions. Open reconstruction still remains the gold standard for thoracic aortic reconstructions involving the arch or visceral vessels. At centers of excellence the operative mortalities for open aortic arch reconstructions with or without replacement of the descending thoracic aorta are reported to be between 2.3% and 12% with stroke rates between 3 and 5%.10-14 The index endovascular repair trials for descending thoracic aortic repair reported perioperative mortality to be in the 1
Mayo Clinic, Rochester, MN, USA
Corresponding Author: Peter Gloviczki, Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Email: [email protected]
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Rana et al range of 2% (Gore-TAG 1.5%, Zenith TX 2.2%, and VALOR 2.1%). A meta-analysis comparing endovascular stent-grafting and open surgery for thoracic aortic disease in 2008 reported stent-grafting to be associated with significant reduction in mortality and major neurological injury.15 All the comparative endovascular data, however, are based on treatment with tube stent-grafts and not with any endovascular branch conservation. It continues to be a topic of hot academic debate whether an aggressive total endovascular approach, a conventional open approach, or a combination of the 2 approaches are better in patients where a simple stent-graft is not possible due to either anatomic constraints or other patient-related factors. In 1999, Dr Quiñones-Baldrich from UCLA introduced the combination of conventional open and endovascular techniques with open debranching followed by endovascular stent-grafting for type IV thoracoabdominal aneurysms.16 Similar concepts of the debranching techniques have since been used for both the supra-aortic vessels and visceral segments, and reported by surgeons around the world. The purpose of these techniques is to minimize open surgery; to limit duration of or eliminate cardiopulmonary bypass (CPB), deep hypothermic circulatory arrest (DHCA), and end organ ischemia; and potentially reduce the incidence of neurological, cardiovascular, and respiratory complications. In terms of arch vessels, combination of open and endovascular techniques have been used with debranching (ascending aortic based or cervical based) and hybrid elephant trunk procedures. In high-risk patients with significant comorbidities, these techniques avoid or shorten the duration of CPB and circulatory arrest. This review discusses the contemporary role of endovascular therapy as an adjunct to open surgery for reconstruction of thoracic aortic arch and assesses a flexible combined approach in the form of hybrid thoracic aortic reconstructions. A total of 24 publications were identified over the past 7 years. Reports with less than 10 patients were excluded. A total of 15 articles encompassing 985 cases of hybrid reconstruction involving the aortic arch, published between 2007 and 2013, were included for the purpose of this review. Major outcomes evaluated were technical success, mortality, stroke, spinal cord injury (SCI), and incidence of delayed endoleaks requiring interventions.
Review of Literature Arch Debranching Arch debranching can be performed in patients with an adequate proximal landing zone within the native aorta. The extent of debranching depends on the proximity or involvement of great vessels with the diseased segment. Arch aneurysms involving or encroaching the origins of
left common carotid artery or innominate artery can be repaired with debranching off the normal ascending aorta in the form of an aorto-brachiocephalic bypass. This requires a full or partial median sternotomy. In general, a partially occluding clamp is used on the ascending aorta to fashion the inflow anastomosis without the need of CBP or circulatory arrest followed by sequential bypasses to the innominate and left carotid arteries, and potentially adding an additional left carotid subclavian bypass.17 In cases where the innominate artery will not be covered by the stent graft, the left common carotid and the left subclavian arteries can be debranched with cervical extraanatomical reconstruction in form of a right to left carotid–carotid or, if needed, an additional left carotid subclavian bypass (see Figure 1). The literature on arch debranching is limited to case reports and small series. In a series of 27 high-risk patients (performed for arch aneurysms in 18, type B dissections in 5, penetrating ulcers in 4 patients), Czerny et al, in 2007, reported in-hospital mortality in 2 patients (7.4%) with no incidence of stroke or SCI.18 Over a mean followup of 15 months, 1-year and 3-year survival in these patients was 83% and 72%, respectively. One patient developed a type III endoleak, which was treated with a stent-graft extension. Roman Gottardi and colleagues reported a series of 73 patients (operated for degenerative aneurysms in 42 patients, type B dissections in 9, penetrating ulcers in 17, traumatic lesions in 2, and coarctation in 3).19 Debranching included left subclavian to carotid transposition in 24, carotid–carotid–subclavian transposition via partial sternotomy in 36, and aortobrachiocephalic bypasses in 13. In-hospital mortality was 6.8%. One patient had a stroke. Mean follow-up was 37 months, with actuarial survival of 90% and 86% at 1 and 3 years, respectively. Delayed type I and III endoleaks occurred in 5.5% of patients. Chad Hughes and the group from Duke University Medical Center in Durham, North Carolina, reported their series of 7 arch debranching and 6 visceral debranching as part of single-stage hybrid thoracic and thoracoabdominal aortic reconstructions in high-risk patients.20 The authors described using custom-made Dacron grafts, either trifurcated or quadrifurcated (Vascutek USA, Ann Arbor, MI), as a single inflow source for all their cases. They had no perioperative mortality, stroke, or SCI. At a mean follow-up of 7.5 months, 100% graft patency with no late mortality was reported. The authors concluded that the hybrid approach was a safe alternative to total open repair for TAAs. Canaud et al, from France, reported 11 cases treated with sequential transposition of left carotid and subclavian arteries via partial upper sternotomy and left cervical extension.21 They had 90.9% technical success and no perioperative mortality. One patient had retrograde type
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Figure 1. Extra-anatomical right common carotid based cervical debranching. Right carotid to left carotid–left subclavian bypass configurations (A, B) and right to left common carotid bypass with left subclavian to left common carotid transposition (C). Published with permission from Mayo Foundation for Medical Education and Research.
A dissection requiring immediate surgical aortic root replacement with circulatory arrest. No patient had stroke or SCI, and 1 patient over a mean follow-up of 31 months developed type I endoleak that was left untreated as it would require zone 0 debranching and patient had mediastinitis. In a series of 26 high-risk patients, Weigang and colleagues from Mainz, Germany, in 2009, reported results of their technique using partial median sternotomy for aortic arch debranching.22 Rapid ventricular pacing with systemic hypotension was employed in all patients for stentgraft deployment, preferably in a single-stage approach. CPB and DHCA were avoided in all patients. The authors selectively used antegrade deployment of stent-grafts via a separate conduit sewn to the debranching graft off the ascending aorta for tight arches. They had 4 (15%) perioperative cardiovascular events. One patient had transient neurological deficit and none had SCI. This report has no follow-up information (see Figure 2). A group from University of Southern California presented experience with 51 patients treated with the hybrid approach.23 The cohort included 16 arch aneurysms, 11 proximal descending TAAs, and 24 thoracoabdominal aortic aneurysms (TAAAs). Twenty-seven patients had debranching of arch vessels and 24 had retrograde visceral debranching. Three fourths of the reconstructions were staged with a mean interval of 28 days in between. Four patients did not complete the second stage.
Technical endovascular success was achieved in 87%. Out of the 27 patients with arch debranching, there was 1 perioperative death (3.7%). Major complications, including 2 strokes, occurred in 9 (33%) patients. Of 47 bypasses, 1 occluded in the postoperative period and required revision. During a mean follow-up of 13 months, 3 endoleaks were identified. Survival was 86% at 1 year and 67% at 3 years. A novel technique to tackle TAAAs in patients with surgical cardiac disease was introduced by Vivacqua and colleagues from Cleveland Clinic in 2011.24 The authors performed antegrade visceral debranching from the ascending aorta using a median sternotomy combined with supra-umbilical laparotomy in 4 patients, concomitant with an associated cardiac procedure (3 coronary artery bypass grafting, with 1 patient also requiring a Bentall procedure, and 1 aortic arch repair). The debranching graft was routed on the right side of the mediastinum and tunneled through the diaphragm using a small incision near the central tendon. The endovascular portion of the repairs was performed 2 to 4 weeks later. In patients with difficult ilio-femoral access, the authors recommended an ascending aorta to axillary bypass with one of the 10-mm limbs as a conduit for endovascular stentgraft deployment, at a later stage. There was no perioperative mortality and no neurological complications. One patient required reoperation for occluded renal bypass (see Figure 3).
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Figure 2. Ascending aorta–based total arch debranching. Partially occlusive side clamp is used to create the proximal anastomosis (A). Distal revascularization is performed with anastomosis to distal innominate artery and side branch to left common carotid artery (B). A side limb can be used on the main limb for antegrade stent-graft deployment (C). The side limb is closed like a patch on completion of repair (D). Published with permission from Mayo Foundation for Medical Education and Research.
Figure 3. Total arch debranching in a patient with type A dissection and prior ascending aortic replacement (A). Intraoperative pictures showing proximal anastomosis to ascending aortic graft and distal reconstruction to right common carotid artery with limbs to left common carotid and right subclavian arteries (B). Retrograde stent-graft deployment from femoral access within the true lumen to seal within ascending aortic graft (C). Follow-up computed tomography scans immediate and after 3 months show progressive thrombosis of the false lumen in the aneurysmal segment (D). Published with permission from Mayo Foundation for Medical Education and Research.
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Table 1. Outcomes of Aortic Arch Debranching Procedures.
Author 18
Czerny et al Gottardi et al19 Weigang et al22 Obitsu et al36 Ham et al23 Bavaria et al37 Canaud et al21 Total (n)/average (%)
Year
Type of Study
2007 2008 2009 2011 2011 2013 2013
Retrospective review Retrospective review Retrospective review Retrospective review Retrospective review Retrospective review Retrospective review
Total Number Technical of Patients Success 27 73 26 55 27 36 11 255
26 (96%) 68 (93%) 100% 100% 25 (93%) 100% 10 (91%) 97.6%
Perioperative Mortality n
%
2 5 4 1 1 3 0 16
7.4 7 15 4 3.7 8.3 0 6
SCI n
Stroke
Late Endoleaks
%
n
%
n
%
0 0 1 1 0 0 1 4 0 0 2 5.6 0 0 4 1.5
0 0 0 1 2 3 0 6
0 0 0 4 7.4 8.3 0 2.4
1 5 3 1 1 11
3.7 7 11 3 9 6.3
Abbreviation: SCI, spinal cord injury.
Midterm results from a prospectively maintained registry of patients undergoing complete arch debranching were recently published.25 Sixty-six patients (48 with aneurysms, 11 with dissections, 6 with penetrating ulcers) were treated with full arch debranching and TEVAR with all repairs extending to the ascending aorta (zone 0). In-hospital mortality was 9%, early complications included a 3% rate of paraplegia and a 5% rate of stroke. Five-year survival was 72%. Two patients had retrograde type A dissections, which warranted careful attention to compliance mismatch between the ascending aorta and the stent-grafts (see Table 1).
Elephant Trunk Techniques Hans Borst in 1983 introduced the elephant trunk procedure for staged reconstruction of aortic arch and descending aorta.26 The arch is replaced with the ascending aorta during the first stage with anastomosis of the graft to the descending thoracic aorta beyond the left subclavian artery and the elephant trunk part of the graft hanging in the proximal descending aorta. The second stage then requires a left thoracotomy for replacement of the descending aorta. The proximal anastomosis of the new graft is performed with the elephant trunk.26 In 2003, Karck and colleagues from Hanover, Germany, introduced the hybrid modification of elephant trunk (frozen elephant trunk) as they reported placement of a stent-graft in an antegrade fashion through the open aortic arch with conventional replacement of the ascending aorta and arch.27 In 2007, these authors published experience with frozen elephant trunk technique in 39 patients, including 21 with dissections and 18 with degenerative aneurysms.28 Early mortality was 12.8% (5 patients). Three patients developed permanent and 2 had transient central neurological deficits while no patient had SCI. Follow-up averaged 22 months; midterm survival was 87%. Complete aneurysm exclusion was 92% in patients who underwent imaging studies
resulting in 9 mm average decrease in maximum aneurysm diameter (see Figure 4). The hybrid elephant trunk procedures have since been performed and reported using 3 strategies: the frozen elephant trunk procedure (as initially described), the endovascular completion at a second stage, and the reversed elephant trunk procedure. From Bari in Italy, Dr Esposito and his colleagues introduced the “Lupiae” technique to treat “Mega Aortic Syndrome” in their description of staged frozen elephant trunk using a specialized prosthesis.29 The procedure was performed in patients with aneurysms of the ascending aorta, arch, and the thoracoabdominal aorta. Eighty-eight patients were treated first with the “Gelweave Lupiae Prosthesis” (Terumo Vascutek, Renfrewshire, Scotland). Endovascular repair was then completed in 80 patients. This innovative prosthesis has a tube Dacron graft with a trifurcated limb coming off from a short main trunk and another 10-mm branch opposite the origin of trifurcated graft with a radiopaque marker to mark the landing zone. The extent of aneurysms treated was proximal to the celiac artery in 60 patients, who underwent an elephant trunk procedure with the Lupiae prosthesis and stent-grafting in the second stage. Fourteen patients also had involvement of the celiac or superior mesenteric arteries and in these one branch of the trifurcation was brought via right mediastinum into the abdomen via an upper abdominal incision and anastomosed with the visceral arteries, as the endograft was extended to cover the paravisceral segment. Six patients had pan-aortic involvement with aneurysms extending below the renal arteries in whom a 3-stage repair was done with separate operation to replace the infrarenal aorta with another Lupiae prosthesis for retrograde visceral debranching and stent-grafting done a month later. In-hospital mortality was 8.4% (2 patients): one patient had intraoperative rupture of the descending thoracic aorta and the other had bowel infarction. There was no stroke or paraplegia, but 3 patients had transient neurological deficits. Three patients had renal failure and
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Figure 4. Staged hybrid elephant trunk reconstruction in a patient with aneurysm from the ascending aorta to the celiac axis (A). Endovascular completion elephant trunk (B) combined with fenestration for the celiac artery and scallop for SMA for adequate distal landing zone (B, C). Published with permission from Mayo Foundation for Medical Education and Research.
2 had bleeding requiring reoperation. Follow-up was 100%, and it ranged from 6 months to 6 years. All patients underwent imaging studies at 6 months and at 1 year. No endoleaks were noted. The authors reported on a mean aortic cross-clamp time of 49.8 minutes and circulatory arrest time of 22.5 minutes, likely attributing to the excellent result; the left subclavian artery was revascularized in all patients (see Table 2). Shimamura and colleagues from Osaka, Japan, reported the largest series of hybrid elephant trunk procedures.30 Their cohort includes 126 patients (57 aortic dissection and 69 aneurysms). All were done at single stage with antegrade stent deployment (frozen elephant trunk) under DHCA and selective cerebral perfusion. The arch was replaced with 4-branched prosthesis. Early mortality was 3.2%. Seven (5.6%) patients had strokes and 8 (6.3%) had spinal cord ischemia (paraplegia in 3, transient paraparesis in 5). Mean follow-up was 60 months, with 63% 5-year survival, 3.9% incidence (5 patients— type I = 3, type III = 2) of delayed endoleaks, with 91.1% 5-year freedom from endoleaks. Kawaharada et al from Sapporo, Japan, reported 31 patients who underwent a hybrid arch repair, all with endovascular elephant trunk completion.31 All had median
sternotomy with CPB and circulatory arrest for arch replacement, followed by either simultaneous or delayed deployment of stent-grafts distally. Technical success was 100%. Two patients (6.4%) had paraparesis and 1 (3.2%) had stroke. Early mortality was 6.4%. Three patients (9.6) had delayed conversion to open surgery for type 1a endoleaks, which resulted from inadequate seal within the surgical elephant trunk. Jim et al from Washington University School of Medicine presented their series of 10 patients with distal aortic arch aneurysms who underwent an endovascular completion of elephant trunks.32 All patients were deemed high risk for open second-stage surgery. Three patients had staged reconstruction and 7 had single-stage repair with an antegrade ascending aortic access. The authors reported 100% technical success, no paraplegia or stroke, and 1 early death. Mean survival was 35 months after surgery. The reversed frozen elephant trunk (RFET) represents the hybrid version of the open reversed elephant trunk (reconstruction of descending thoracic aorta followed by arch reconstruction). A series of 19 patients was reported from Cleveland Clinic who underwent RFET when the clinical scenario warranted the stent-graft placement before
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Table 2. Outcomes of Hybrid Elephant Trunk Procedures.
Author 28
Baraki et al Shimamura et al30 Kawaharada et al31 Esposito et al29 Obitsu et al36 Jakob et al34 Jim et al32 Czerny et al25 Lima et al33 Total (n)/average (%)
Year
Type of Study
2007 2008 2009 2011 2011 2011 2011 2012 2012
Retrospective review Retrospective review Retrospective review Retrospective review Retrospective review Prospective registry Retrospective review Prospective registry Retrospective review
Perioperative Mortality
Total Patients
Technical Success
39 126 31 80 55 274 10 66 50 731
38 (97%) 100% 100% 80/88 (91%) 100% 100% 100% 100% 100% 98.4%
SCI
Stroke
n
%
n
%
n
%
5 4 2 8 2 33 1 6 3 64
12.8 3.2 6.4 8.4 11.7 12 10 9 6 8.7
0 3 2 0 0 22 0 2 4 31
0 2.4 6.4 0 0 8 0 3 8 4.5
5 12.8 7 5.6 1 3.2 0 0 0 0 16 6 0 0 3 5 5 10 37 5
Late Endoleaks n
%
3 5 3 0 1 29 1 4 5 51
7.6 3.9 9.6 0 5.8 10.5 10 6 10 7
Abbreviation: SCI, spinal cord injury.
the open arch reconstruction.33 This was published as part of a cohort of 50 patients with FETs. Median interval between stent-grafting to arch reconstruction in the RFET patients was 2.3 months. There were 3 early deaths overall (6%), 1 in the RFET group. Stroke occurred in 5 patients (10%) overall and 1 in the RFET group, while incidence of SCI was reported in 4 patients (transient in 3), none of which were in the RFET group. After a mean follow-up of 17 months, actuarial survival was 86% at 2 years. There were 5 late endoleaks that required re-interventions, and at 30-day follow-up 67% of the patients with dissection had complete false lumen thrombosis. A hybrid open stent-graft (E-Vita hybrid prosthesis; JOTEC GmbH, Hechingen, Germany) was developed and introduced in 2005 for complex aortic disease involving the arch and the descending aorta. This is in configuration of a frozen elephant trunk but the open aortic conduit and the stent-graft are integrated in a single prosthesis. Results from the prospectively maintained international E-Vita registry were published in 2011.34 A total of 274 patients underwent repair of complex thoracic aortic disease (aortic dissection in 190, aneurysms in 84) in a frozen elephant trunk configuration. In-hospital mortality was 15%. Sixteen (6%) patients had stroke and 22 (8%) suffered SCI. Median follow-up was 59 months, with 92% false lumen thrombosis. Actuarial 5-year survival 74%, with 82% freedom from secondary endovascular intervention.
Experience With Combined Debranching and Hybrid Elephant Trunk Procedures Zhou and colleagues from the Baylor College of Medicine reported their experience with the hybrid thoracic aortic reconstructions in high-risk patients in 2006.35 These authors had a total of 31 patients, including 16 patients with ascending aortic and arch aneurysms and 15 patients with para visceral aortic involvement. Three patients had
total aortic aneurysms involving both the ascending and descending aortas. The mean aneurysm diameter was 6.2 cm, with all patients deemed high risk for conventional open repair. Eleven patients had prior aortic aneurysm repairs done while 16 had insufficient proximal landing zones (PLZs). Out of these, 3 patients required full arch reconstruction with 2 having elephant trunk creation. Seven patients had ascending aorta to supra-aortic trunk bypasses and 1 patient got descending aorta to supraaortic trunk bypass. A total of 13 carotid (CCA) to CCA bypasses and 25 CCA–subclavian artery bypasses were also performed as adjunctive procedures. Additionally, 13 patients required conduits for access, including 1 patient who required the use of carotid artery as access vessel for stent-graft of an ascending aortic pseudoaneurysm and 12 patients who needed iliac conduits. Fifteen patients underwent a total of 40 visceral antegrade or retrograde bypasses. Gore TAG (WL Gore Inc, Flagstaff, AZ) was used as stent-graft in all patients. Technical success was achieved in 100% of patients. Perioperative mortality was 3.2% (1 patient) due to severe hemorrhage. A total of 6.4% (2 patients) had immediate type II endoleaks that resolved by the 1-month follow-up. Three patients (9.6%) had other procedure-related complications. The authors effectively introduced and documented safety and efficacy of the hybrid approach in treating these lesions in the high-risk patient group. Another series was published in 2011 from Tokyo, Japan. Obitsu et al reported 55 cases of hybrid TAA repair using custom-made stent-grafts.36 Seventeen (8 for arch aneurysms, 9 for type A dissections) of their patients underwent arch reconstruction with an elephant trunk as the landing zone for stent-grafts in a staged fashion. Another 25 patients had a variety of supra-aortic trunk debranching. The remaining 13 patients had visceral debranching. These authors used a combination of staged and nonstaged approaches but do not specify exact numbers. There were 3 perioperative deaths while 2 patients
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Rana et al suffered SCI and 1 had stroke. Three patients with type A dissection had delayed aneurysm growth due to retrograde false lumen filling with 2 treated with open TAAA repair and third died from an aortoesophageal fistula. Two patients had repeat stent-grafting for a type III endoleak and an intimal tear. Dr Bavaria and the group from University of Pennsylvania Medical Center presented a series of 47 patients with aortic arch aneurysms treated with a hybrid approach.37 Eleven had a modified elephant trunk procedure and were excluded from this analysis. Twenty-eight patients had arch debranching off the ascending aorta, with (8) or without (16) CPB, and simultaneous or delayed stent-grafting across the native arch. Eight patients had complete debranching with replacement of ascending aorta with CPB and sometimes brief circulatory arrest. Paraplegia occurred in 5.5% and stroke in 8%. In-hospital mortality was 8% as 2 patients died from neurological events. Survival was 60% and 48% at 3 and 5 years, respectively, with a 2.7% re-intervention rate. There were no type 1 or 3 endoleaks during follow-up.
Discussion Thoracic aortic aneurysms with involvement of supraaortic vessels and the visceral segment remain a challenge with the ever-evolving approach to management. Total endovascular exclusion is now the obvious preferred approach for the descending thorac aorta when good proximal and distal landing zones exist. Whether advanced endovascular technology with branched and fenestrated devices will replace conventional open surgery in the ascending aorta and arch disease with no or short landing zones remains to be seen. Open surgery to date is the gold standard for reconstructions involving the ascending aorta and the arch vessels. In experienced hands, the hybrid approach with open arch debranching has shown to be effective, with outcomes comparable to open reconstructions, in spite of the fact that most of the patients reported were higher risk and hybrid approach was often opted for patients who were not suitable total open repair candidates and were neither suitable for total endovascular repair. Based on our review of contemporary data from hybrid aortic reconstructions and of open reconstructions, we currently pursue a flexible approach with application of a combination of open and endovascular techniques to approach the ascending aortic and aortic arch pathologies when feasible. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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16. Quiñones-Baldrich WJ, Panetta TF, Vescera CL, Kashyap VS. Repair of type IV thoracoabdominal aneurysm with a combined endovascular and surgical approach. J Vasc Surg. 1999;30:555-560. 17. Mozes G, Gloviczki P, Huang Y. Atherosclerotic occlusive disease. In: Coselli JS, and LeMaire SA, eds. Aortic Arch Surgery: Principles, Strategies, and Outcomes. Hoboken, NJ: Wiley-Blackwell; 2009:307-321. 18. Czerny M, Gottardi R, Zimpfer D, et al. Mid-term results of supraaortic transpositions for extended endovascular repair of aortic arch pathologies. Eur J Cardiothorac Surg. 2007;31:623-627. 19. Gottardi R, Funovics M, Eggers N, et al. Supra-aortic transposition for combined vascular and endovascular repair of aortic arch pathology. Ann Thorac Surg. 2008;86:1524-1529. 20. Hughes GC, Nienaber JJ, Bush EL, Daneshmand MA, McCann RL. Use of custom Dacron branch grafts for “hybrid” aortic debranching during endovascular aneurysm repair of thoracic and thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg. 2008;136:21-28. 21. Canaud L, Joyeux F, Ziza V, Branchereau P, Marty-Ané C, Alric P. Hemi-aortic arch debranching for hybrid aortic arch repair by sequential transposition of the left common carotid and subclavian arteries. J Thorac Cardiovasc Surg. 2013;145:764-767. 22. Weigang E, Parker J, Czerny M. Endovascular aortic arch repair after aortic arch de-branching. Ann Thorac Surg. 2009;87:603-607. 23. Ham S, Chong T, Moos J, et al. Arch and visceral/renal debranching combined with endovascular repair of thoracic and thoracoabdominal aortic aneurysms. J Vasc Surg. 2011;54:30-41. 24. Vivacqua A, Albacker TB, Roselli EE. Hybrid thoracoabdominal aneurysm repair with antegrade visceral debranching from ascending aorta: concomitant cardiac surgery and stent-grafting. Ann Thorac Surg. 2011;92:2275-2277. 25. Czerny M, Weigang E, Sodeck G, et al. Targeting landing zone 0 by total arch rerouting and TEVAR: midterm results of a transcontinental registry. Ann Thorac Surg. 2012;94:84-89. 26. Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement using “elephant trunk” prosthesis. Thorac Cardiovasc Surg. 1983;31:37-40.
27. Karck M, Chavan A, Hagl C, Friedrich H, Galanski M, Haverich A. The frozen elephant trunk technique: a new treatment for thoracic aortic aneurysms. J Thorac Cardiovasc Surg. 2003;125:1550-1553. 28. Baraki H, Hagl C, Khaladj N, et al. The frozen elephant trunk technique for treatment of thoracic aortic aneurysms. Ann Thorac Surg. 2007;83:S819-S823. 29. Esposito G, Cappabianca G, Contegiacomo G, Labriola G, Gallo N, Labriola C. Hybrid repair of thoracic and thoracoabdominal aortic aneurysms (mega aortic syndrome) with Lupiae technique. Innovations (Phila). 2011;6: 366-372. 30. Shimamura K, Kuratani T, Matsumiya G. Long-term results of the open stent-grafting technique for extended aortic arch disease. J Thorac Cardiovasc Surg. 2008;135: 1261-1269. 31. Kawaharada N, Kurimoto Y, Ito T. Hybrid treatment for aortic arch and proximal descending thoracic aneurysm: experience with stent grafting for second-stage elephant trunk repair. Eur J Cardiothorac Surg. 2009;36:956-961. 32. Jim J, Moon MR, Rubin BG, Sicard GA, Sanchez LA. Hybrid repair of distal arch aortic aneurysms: Endovascular elephant trunk completion. Ann Vasc Surg. 2011;25:598-604. 33. Lima B, Roselli E, Soltesz E, et al. Modified and “reverse” frozen elephant trunk repairs for extensive disease and complications after stent grafting. Ann Thorac Surg. 2012;93:103-109. 34. Jakob H, Tsagakis K, Pacini D, et al. The International E-vita open registry: data sets of 274 patients. J Cardiovasc Surg (Torino). 2011;52:717-723. 35. 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;44:688-693. 36. Obitsu Y, Koizumi N, Takahashi S, et al. Hybrid procedures combining conventional and thoracic aortic repair for thoracic aortic aneurysms. Surg Today. 2011;44: 922-927. 37. Bavaria J, Vallabhajosyula P, Moeller P, Szeto W, Desai N, Pochettino A. Hybrid approaches in the treatment of aortic arch aneurysms: postoperative and midterm outcomes. J Thorac Cardiovasc Surg. 2013;145:S85-S90.
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Endovascular Stenting With Open Surgery for Reconstructions of the Ascending Aorta and the Aortic Arch: A Review of Indications and Results of Hybrid Techniques Muhammad A. Rana, Peter Gloviczki and Gustavo S. Oderich PERSPECT VASC SURG ENDOVASC THER 2012 24: 184 originally published online 14 August 2013 DOI: 10.1177/1531003513497984 The online version of this article can be found at: http://pvs.sagepub.com/content/24/4/184
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PVSXXX10.1177/1531003513497984Perspectives in Vascular Surgery and Endovascular TherapyRana et al
Feature Article
Endovascular Stenting With Open Surgery for Reconstructions of the Ascending Aorta and the Aortic Arch: A Review of Indications and Results of Hybrid Techniques
Perspectives in Vascular Surgery and Endovascular Therapy 24(4) 184–192 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1531003513497984 pvs.sagepub.com
Muhammad A. Rana, MD1, Peter Gloviczki, MD1, and Gustavo S. Oderich, MD1
Abstract Hybrid approaches for repair of aneurysms involving the ascending aorta and the aortic arch have been developed to avoid or reduce duration of cardiopulmonary bypass and circulatory arrest and to decrease operative time, blood loss, hospital stay, morbidity, and mortality. These include ascending aorta–based debranching or cervical extraanatomical bypasses followed by stent-grafting. In patients with associated descending aortic aneurysms, the elephant trunk technique is used followed by stent-grafting of the descending thoracic aorta. A review of the literature of hybrid aortic arch reconstructions, published over past 7 years, reveals perioperative mortalities from 0% to 13%, stroke from 0% to 10%, and spinal cord injury in 0% to 13%. The outcomes are comparable to contemporary results from total open and total endovascular reconstructions in spite of the fact that the hybrid approach is generally taken in patients with high surgical risk for open repair and with prohibitive anatomy for total endovascular repair. Keywords hybrid, aortic arch, frozen elephant trunk, elephant trunk, debranching, arch debranching, aortic arch aneurysms, thoracic aortic aneurysms
Background The incidence of thoracic aortic aneurysms (TAAs) is reported to be more than 10 per 100 000 person-years (5.9% in the early 1980s) and has almost doubled over the past 2 decades.1-3 This carries an overall risk of rupture of about 20% after 5 years, which is 31% for aneurysms with a diameter of 6 cm or larger.1,4 Dake and his colleagues’ report of the first endovascular repair of a TAA in 1994 was a major milestone in the management of this disease.5 The US Food and Drug Administration approved thoracic aortic stent-grafting for aneurysmal disease in April 2005. Stent-grafting has been mainly limited to the unbranched segment of the aorta between the left subclavian and the celiac arteries. Recently, however, branched and fenestrated stent-grafts have been used to successfully treat aneurysms involving the arch vessels or the visceral aorta, with some investigators calling it the best option for treating the para-visceral segment.5-8 Acceptable results have also been reported after total endovascular repair of infected thoracic aorta.9 With the surge of endovascular repair for thoracic aortic pathology, the future role of conventional open approaches
to these lesions is being questioned. Total endovascular options at present are limited by the aneurysm anatomy and extent; however, with ongoing advances it has become a matter of controversy whether open or endovascular option will be the best to approach to any TAA. There is a tendency to compare the results of a lesser extent coverage of the aorta with endovascular stent-grafts to more extensive open aortic reconstructions. Open reconstruction still remains the gold standard for thoracic aortic reconstructions involving the arch or visceral vessels. At centers of excellence the operative mortalities for open aortic arch reconstructions with or without replacement of the descending thoracic aorta are reported to be between 2.3% and 12% with stroke rates between 3 and 5%.10-14 The index endovascular repair trials for descending thoracic aortic repair reported perioperative mortality to be in the 1
Mayo Clinic, Rochester, MN, USA
Corresponding Author: Peter Gloviczki, Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Email: [email protected]
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Rana et al range of 2% (Gore-TAG 1.5%, Zenith TX 2.2%, and VALOR 2.1%). A meta-analysis comparing endovascular stent-grafting and open surgery for thoracic aortic disease in 2008 reported stent-grafting to be associated with significant reduction in mortality and major neurological injury.15 All the comparative endovascular data, however, are based on treatment with tube stent-grafts and not with any endovascular branch conservation. It continues to be a topic of hot academic debate whether an aggressive total endovascular approach, a conventional open approach, or a combination of the 2 approaches are better in patients where a simple stent-graft is not possible due to either anatomic constraints or other patient-related factors. In 1999, Dr Quiñones-Baldrich from UCLA introduced the combination of conventional open and endovascular techniques with open debranching followed by endovascular stent-grafting for type IV thoracoabdominal aneurysms.16 Similar concepts of the debranching techniques have since been used for both the supra-aortic vessels and visceral segments, and reported by surgeons around the world. The purpose of these techniques is to minimize open surgery; to limit duration of or eliminate cardiopulmonary bypass (CPB), deep hypothermic circulatory arrest (DHCA), and end organ ischemia; and potentially reduce the incidence of neurological, cardiovascular, and respiratory complications. In terms of arch vessels, combination of open and endovascular techniques have been used with debranching (ascending aortic based or cervical based) and hybrid elephant trunk procedures. In high-risk patients with significant comorbidities, these techniques avoid or shorten the duration of CPB and circulatory arrest. This review discusses the contemporary role of endovascular therapy as an adjunct to open surgery for reconstruction of thoracic aortic arch and assesses a flexible combined approach in the form of hybrid thoracic aortic reconstructions. A total of 24 publications were identified over the past 7 years. Reports with less than 10 patients were excluded. A total of 15 articles encompassing 985 cases of hybrid reconstruction involving the aortic arch, published between 2007 and 2013, were included for the purpose of this review. Major outcomes evaluated were technical success, mortality, stroke, spinal cord injury (SCI), and incidence of delayed endoleaks requiring interventions.
Review of Literature Arch Debranching Arch debranching can be performed in patients with an adequate proximal landing zone within the native aorta. The extent of debranching depends on the proximity or involvement of great vessels with the diseased segment. Arch aneurysms involving or encroaching the origins of
left common carotid artery or innominate artery can be repaired with debranching off the normal ascending aorta in the form of an aorto-brachiocephalic bypass. This requires a full or partial median sternotomy. In general, a partially occluding clamp is used on the ascending aorta to fashion the inflow anastomosis without the need of CBP or circulatory arrest followed by sequential bypasses to the innominate and left carotid arteries, and potentially adding an additional left carotid subclavian bypass.17 In cases where the innominate artery will not be covered by the stent graft, the left common carotid and the left subclavian arteries can be debranched with cervical extraanatomical reconstruction in form of a right to left carotid–carotid or, if needed, an additional left carotid subclavian bypass (see Figure 1). The literature on arch debranching is limited to case reports and small series. In a series of 27 high-risk patients (performed for arch aneurysms in 18, type B dissections in 5, penetrating ulcers in 4 patients), Czerny et al, in 2007, reported in-hospital mortality in 2 patients (7.4%) with no incidence of stroke or SCI.18 Over a mean followup of 15 months, 1-year and 3-year survival in these patients was 83% and 72%, respectively. One patient developed a type III endoleak, which was treated with a stent-graft extension. Roman Gottardi and colleagues reported a series of 73 patients (operated for degenerative aneurysms in 42 patients, type B dissections in 9, penetrating ulcers in 17, traumatic lesions in 2, and coarctation in 3).19 Debranching included left subclavian to carotid transposition in 24, carotid–carotid–subclavian transposition via partial sternotomy in 36, and aortobrachiocephalic bypasses in 13. In-hospital mortality was 6.8%. One patient had a stroke. Mean follow-up was 37 months, with actuarial survival of 90% and 86% at 1 and 3 years, respectively. Delayed type I and III endoleaks occurred in 5.5% of patients. Chad Hughes and the group from Duke University Medical Center in Durham, North Carolina, reported their series of 7 arch debranching and 6 visceral debranching as part of single-stage hybrid thoracic and thoracoabdominal aortic reconstructions in high-risk patients.20 The authors described using custom-made Dacron grafts, either trifurcated or quadrifurcated (Vascutek USA, Ann Arbor, MI), as a single inflow source for all their cases. They had no perioperative mortality, stroke, or SCI. At a mean follow-up of 7.5 months, 100% graft patency with no late mortality was reported. The authors concluded that the hybrid approach was a safe alternative to total open repair for TAAs. Canaud et al, from France, reported 11 cases treated with sequential transposition of left carotid and subclavian arteries via partial upper sternotomy and left cervical extension.21 They had 90.9% technical success and no perioperative mortality. One patient had retrograde type
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Figure 1. Extra-anatomical right common carotid based cervical debranching. Right carotid to left carotid–left subclavian bypass configurations (A, B) and right to left common carotid bypass with left subclavian to left common carotid transposition (C). Published with permission from Mayo Foundation for Medical Education and Research.
A dissection requiring immediate surgical aortic root replacement with circulatory arrest. No patient had stroke or SCI, and 1 patient over a mean follow-up of 31 months developed type I endoleak that was left untreated as it would require zone 0 debranching and patient had mediastinitis. In a series of 26 high-risk patients, Weigang and colleagues from Mainz, Germany, in 2009, reported results of their technique using partial median sternotomy for aortic arch debranching.22 Rapid ventricular pacing with systemic hypotension was employed in all patients for stentgraft deployment, preferably in a single-stage approach. CPB and DHCA were avoided in all patients. The authors selectively used antegrade deployment of stent-grafts via a separate conduit sewn to the debranching graft off the ascending aorta for tight arches. They had 4 (15%) perioperative cardiovascular events. One patient had transient neurological deficit and none had SCI. This report has no follow-up information (see Figure 2). A group from University of Southern California presented experience with 51 patients treated with the hybrid approach.23 The cohort included 16 arch aneurysms, 11 proximal descending TAAs, and 24 thoracoabdominal aortic aneurysms (TAAAs). Twenty-seven patients had debranching of arch vessels and 24 had retrograde visceral debranching. Three fourths of the reconstructions were staged with a mean interval of 28 days in between. Four patients did not complete the second stage.
Technical endovascular success was achieved in 87%. Out of the 27 patients with arch debranching, there was 1 perioperative death (3.7%). Major complications, including 2 strokes, occurred in 9 (33%) patients. Of 47 bypasses, 1 occluded in the postoperative period and required revision. During a mean follow-up of 13 months, 3 endoleaks were identified. Survival was 86% at 1 year and 67% at 3 years. A novel technique to tackle TAAAs in patients with surgical cardiac disease was introduced by Vivacqua and colleagues from Cleveland Clinic in 2011.24 The authors performed antegrade visceral debranching from the ascending aorta using a median sternotomy combined with supra-umbilical laparotomy in 4 patients, concomitant with an associated cardiac procedure (3 coronary artery bypass grafting, with 1 patient also requiring a Bentall procedure, and 1 aortic arch repair). The debranching graft was routed on the right side of the mediastinum and tunneled through the diaphragm using a small incision near the central tendon. The endovascular portion of the repairs was performed 2 to 4 weeks later. In patients with difficult ilio-femoral access, the authors recommended an ascending aorta to axillary bypass with one of the 10-mm limbs as a conduit for endovascular stentgraft deployment, at a later stage. There was no perioperative mortality and no neurological complications. One patient required reoperation for occluded renal bypass (see Figure 3).
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Figure 2. Ascending aorta–based total arch debranching. Partially occlusive side clamp is used to create the proximal anastomosis (A). Distal revascularization is performed with anastomosis to distal innominate artery and side branch to left common carotid artery (B). A side limb can be used on the main limb for antegrade stent-graft deployment (C). The side limb is closed like a patch on completion of repair (D). Published with permission from Mayo Foundation for Medical Education and Research.
Figure 3. Total arch debranching in a patient with type A dissection and prior ascending aortic replacement (A). Intraoperative pictures showing proximal anastomosis to ascending aortic graft and distal reconstruction to right common carotid artery with limbs to left common carotid and right subclavian arteries (B). Retrograde stent-graft deployment from femoral access within the true lumen to seal within ascending aortic graft (C). Follow-up computed tomography scans immediate and after 3 months show progressive thrombosis of the false lumen in the aneurysmal segment (D). Published with permission from Mayo Foundation for Medical Education and Research.
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Table 1. Outcomes of Aortic Arch Debranching Procedures.
Author 18
Czerny et al Gottardi et al19 Weigang et al22 Obitsu et al36 Ham et al23 Bavaria et al37 Canaud et al21 Total (n)/average (%)
Year
Type of Study
2007 2008 2009 2011 2011 2013 2013
Retrospective review Retrospective review Retrospective review Retrospective review Retrospective review Retrospective review Retrospective review
Total Number Technical of Patients Success 27 73 26 55 27 36 11 255
26 (96%) 68 (93%) 100% 100% 25 (93%) 100% 10 (91%) 97.6%
Perioperative Mortality n
%
2 5 4 1 1 3 0 16
7.4 7 15 4 3.7 8.3 0 6
SCI n
Stroke
Late Endoleaks
%
n
%
n
%
0 0 1 1 0 0 1 4 0 0 2 5.6 0 0 4 1.5
0 0 0 1 2 3 0 6
0 0 0 4 7.4 8.3 0 2.4
1 5 3 1 1 11
3.7 7 11 3 9 6.3
Abbreviation: SCI, spinal cord injury.
Midterm results from a prospectively maintained registry of patients undergoing complete arch debranching were recently published.25 Sixty-six patients (48 with aneurysms, 11 with dissections, 6 with penetrating ulcers) were treated with full arch debranching and TEVAR with all repairs extending to the ascending aorta (zone 0). In-hospital mortality was 9%, early complications included a 3% rate of paraplegia and a 5% rate of stroke. Five-year survival was 72%. Two patients had retrograde type A dissections, which warranted careful attention to compliance mismatch between the ascending aorta and the stent-grafts (see Table 1).
Elephant Trunk Techniques Hans Borst in 1983 introduced the elephant trunk procedure for staged reconstruction of aortic arch and descending aorta.26 The arch is replaced with the ascending aorta during the first stage with anastomosis of the graft to the descending thoracic aorta beyond the left subclavian artery and the elephant trunk part of the graft hanging in the proximal descending aorta. The second stage then requires a left thoracotomy for replacement of the descending aorta. The proximal anastomosis of the new graft is performed with the elephant trunk.26 In 2003, Karck and colleagues from Hanover, Germany, introduced the hybrid modification of elephant trunk (frozen elephant trunk) as they reported placement of a stent-graft in an antegrade fashion through the open aortic arch with conventional replacement of the ascending aorta and arch.27 In 2007, these authors published experience with frozen elephant trunk technique in 39 patients, including 21 with dissections and 18 with degenerative aneurysms.28 Early mortality was 12.8% (5 patients). Three patients developed permanent and 2 had transient central neurological deficits while no patient had SCI. Follow-up averaged 22 months; midterm survival was 87%. Complete aneurysm exclusion was 92% in patients who underwent imaging studies
resulting in 9 mm average decrease in maximum aneurysm diameter (see Figure 4). The hybrid elephant trunk procedures have since been performed and reported using 3 strategies: the frozen elephant trunk procedure (as initially described), the endovascular completion at a second stage, and the reversed elephant trunk procedure. From Bari in Italy, Dr Esposito and his colleagues introduced the “Lupiae” technique to treat “Mega Aortic Syndrome” in their description of staged frozen elephant trunk using a specialized prosthesis.29 The procedure was performed in patients with aneurysms of the ascending aorta, arch, and the thoracoabdominal aorta. Eighty-eight patients were treated first with the “Gelweave Lupiae Prosthesis” (Terumo Vascutek, Renfrewshire, Scotland). Endovascular repair was then completed in 80 patients. This innovative prosthesis has a tube Dacron graft with a trifurcated limb coming off from a short main trunk and another 10-mm branch opposite the origin of trifurcated graft with a radiopaque marker to mark the landing zone. The extent of aneurysms treated was proximal to the celiac artery in 60 patients, who underwent an elephant trunk procedure with the Lupiae prosthesis and stent-grafting in the second stage. Fourteen patients also had involvement of the celiac or superior mesenteric arteries and in these one branch of the trifurcation was brought via right mediastinum into the abdomen via an upper abdominal incision and anastomosed with the visceral arteries, as the endograft was extended to cover the paravisceral segment. Six patients had pan-aortic involvement with aneurysms extending below the renal arteries in whom a 3-stage repair was done with separate operation to replace the infrarenal aorta with another Lupiae prosthesis for retrograde visceral debranching and stent-grafting done a month later. In-hospital mortality was 8.4% (2 patients): one patient had intraoperative rupture of the descending thoracic aorta and the other had bowel infarction. There was no stroke or paraplegia, but 3 patients had transient neurological deficits. Three patients had renal failure and
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Figure 4. Staged hybrid elephant trunk reconstruction in a patient with aneurysm from the ascending aorta to the celiac axis (A). Endovascular completion elephant trunk (B) combined with fenestration for the celiac artery and scallop for SMA for adequate distal landing zone (B, C). Published with permission from Mayo Foundation for Medical Education and Research.
2 had bleeding requiring reoperation. Follow-up was 100%, and it ranged from 6 months to 6 years. All patients underwent imaging studies at 6 months and at 1 year. No endoleaks were noted. The authors reported on a mean aortic cross-clamp time of 49.8 minutes and circulatory arrest time of 22.5 minutes, likely attributing to the excellent result; the left subclavian artery was revascularized in all patients (see Table 2). Shimamura and colleagues from Osaka, Japan, reported the largest series of hybrid elephant trunk procedures.30 Their cohort includes 126 patients (57 aortic dissection and 69 aneurysms). All were done at single stage with antegrade stent deployment (frozen elephant trunk) under DHCA and selective cerebral perfusion. The arch was replaced with 4-branched prosthesis. Early mortality was 3.2%. Seven (5.6%) patients had strokes and 8 (6.3%) had spinal cord ischemia (paraplegia in 3, transient paraparesis in 5). Mean follow-up was 60 months, with 63% 5-year survival, 3.9% incidence (5 patients— type I = 3, type III = 2) of delayed endoleaks, with 91.1% 5-year freedom from endoleaks. Kawaharada et al from Sapporo, Japan, reported 31 patients who underwent a hybrid arch repair, all with endovascular elephant trunk completion.31 All had median
sternotomy with CPB and circulatory arrest for arch replacement, followed by either simultaneous or delayed deployment of stent-grafts distally. Technical success was 100%. Two patients (6.4%) had paraparesis and 1 (3.2%) had stroke. Early mortality was 6.4%. Three patients (9.6) had delayed conversion to open surgery for type 1a endoleaks, which resulted from inadequate seal within the surgical elephant trunk. Jim et al from Washington University School of Medicine presented their series of 10 patients with distal aortic arch aneurysms who underwent an endovascular completion of elephant trunks.32 All patients were deemed high risk for open second-stage surgery. Three patients had staged reconstruction and 7 had single-stage repair with an antegrade ascending aortic access. The authors reported 100% technical success, no paraplegia or stroke, and 1 early death. Mean survival was 35 months after surgery. The reversed frozen elephant trunk (RFET) represents the hybrid version of the open reversed elephant trunk (reconstruction of descending thoracic aorta followed by arch reconstruction). A series of 19 patients was reported from Cleveland Clinic who underwent RFET when the clinical scenario warranted the stent-graft placement before
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Table 2. Outcomes of Hybrid Elephant Trunk Procedures.
Author 28
Baraki et al Shimamura et al30 Kawaharada et al31 Esposito et al29 Obitsu et al36 Jakob et al34 Jim et al32 Czerny et al25 Lima et al33 Total (n)/average (%)
Year
Type of Study
2007 2008 2009 2011 2011 2011 2011 2012 2012
Retrospective review Retrospective review Retrospective review Retrospective review Retrospective review Prospective registry Retrospective review Prospective registry Retrospective review
Perioperative Mortality
Total Patients
Technical Success
39 126 31 80 55 274 10 66 50 731
38 (97%) 100% 100% 80/88 (91%) 100% 100% 100% 100% 100% 98.4%
SCI
Stroke
n
%
n
%
n
%
5 4 2 8 2 33 1 6 3 64
12.8 3.2 6.4 8.4 11.7 12 10 9 6 8.7
0 3 2 0 0 22 0 2 4 31
0 2.4 6.4 0 0 8 0 3 8 4.5
5 12.8 7 5.6 1 3.2 0 0 0 0 16 6 0 0 3 5 5 10 37 5
Late Endoleaks n
%
3 5 3 0 1 29 1 4 5 51
7.6 3.9 9.6 0 5.8 10.5 10 6 10 7
Abbreviation: SCI, spinal cord injury.
the open arch reconstruction.33 This was published as part of a cohort of 50 patients with FETs. Median interval between stent-grafting to arch reconstruction in the RFET patients was 2.3 months. There were 3 early deaths overall (6%), 1 in the RFET group. Stroke occurred in 5 patients (10%) overall and 1 in the RFET group, while incidence of SCI was reported in 4 patients (transient in 3), none of which were in the RFET group. After a mean follow-up of 17 months, actuarial survival was 86% at 2 years. There were 5 late endoleaks that required re-interventions, and at 30-day follow-up 67% of the patients with dissection had complete false lumen thrombosis. A hybrid open stent-graft (E-Vita hybrid prosthesis; JOTEC GmbH, Hechingen, Germany) was developed and introduced in 2005 for complex aortic disease involving the arch and the descending aorta. This is in configuration of a frozen elephant trunk but the open aortic conduit and the stent-graft are integrated in a single prosthesis. Results from the prospectively maintained international E-Vita registry were published in 2011.34 A total of 274 patients underwent repair of complex thoracic aortic disease (aortic dissection in 190, aneurysms in 84) in a frozen elephant trunk configuration. In-hospital mortality was 15%. Sixteen (6%) patients had stroke and 22 (8%) suffered SCI. Median follow-up was 59 months, with 92% false lumen thrombosis. Actuarial 5-year survival 74%, with 82% freedom from secondary endovascular intervention.
Experience With Combined Debranching and Hybrid Elephant Trunk Procedures Zhou and colleagues from the Baylor College of Medicine reported their experience with the hybrid thoracic aortic reconstructions in high-risk patients in 2006.35 These authors had a total of 31 patients, including 16 patients with ascending aortic and arch aneurysms and 15 patients with para visceral aortic involvement. Three patients had
total aortic aneurysms involving both the ascending and descending aortas. The mean aneurysm diameter was 6.2 cm, with all patients deemed high risk for conventional open repair. Eleven patients had prior aortic aneurysm repairs done while 16 had insufficient proximal landing zones (PLZs). Out of these, 3 patients required full arch reconstruction with 2 having elephant trunk creation. Seven patients had ascending aorta to supra-aortic trunk bypasses and 1 patient got descending aorta to supraaortic trunk bypass. A total of 13 carotid (CCA) to CCA bypasses and 25 CCA–subclavian artery bypasses were also performed as adjunctive procedures. Additionally, 13 patients required conduits for access, including 1 patient who required the use of carotid artery as access vessel for stent-graft of an ascending aortic pseudoaneurysm and 12 patients who needed iliac conduits. Fifteen patients underwent a total of 40 visceral antegrade or retrograde bypasses. Gore TAG (WL Gore Inc, Flagstaff, AZ) was used as stent-graft in all patients. Technical success was achieved in 100% of patients. Perioperative mortality was 3.2% (1 patient) due to severe hemorrhage. A total of 6.4% (2 patients) had immediate type II endoleaks that resolved by the 1-month follow-up. Three patients (9.6%) had other procedure-related complications. The authors effectively introduced and documented safety and efficacy of the hybrid approach in treating these lesions in the high-risk patient group. Another series was published in 2011 from Tokyo, Japan. Obitsu et al reported 55 cases of hybrid TAA repair using custom-made stent-grafts.36 Seventeen (8 for arch aneurysms, 9 for type A dissections) of their patients underwent arch reconstruction with an elephant trunk as the landing zone for stent-grafts in a staged fashion. Another 25 patients had a variety of supra-aortic trunk debranching. The remaining 13 patients had visceral debranching. These authors used a combination of staged and nonstaged approaches but do not specify exact numbers. There were 3 perioperative deaths while 2 patients
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Rana et al suffered SCI and 1 had stroke. Three patients with type A dissection had delayed aneurysm growth due to retrograde false lumen filling with 2 treated with open TAAA repair and third died from an aortoesophageal fistula. Two patients had repeat stent-grafting for a type III endoleak and an intimal tear. Dr Bavaria and the group from University of Pennsylvania Medical Center presented a series of 47 patients with aortic arch aneurysms treated with a hybrid approach.37 Eleven had a modified elephant trunk procedure and were excluded from this analysis. Twenty-eight patients had arch debranching off the ascending aorta, with (8) or without (16) CPB, and simultaneous or delayed stent-grafting across the native arch. Eight patients had complete debranching with replacement of ascending aorta with CPB and sometimes brief circulatory arrest. Paraplegia occurred in 5.5% and stroke in 8%. In-hospital mortality was 8% as 2 patients died from neurological events. Survival was 60% and 48% at 3 and 5 years, respectively, with a 2.7% re-intervention rate. There were no type 1 or 3 endoleaks during follow-up.
Discussion Thoracic aortic aneurysms with involvement of supraaortic vessels and the visceral segment remain a challenge with the ever-evolving approach to management. Total endovascular exclusion is now the obvious preferred approach for the descending thorac aorta when good proximal and distal landing zones exist. Whether advanced endovascular technology with branched and fenestrated devices will replace conventional open surgery in the ascending aorta and arch disease with no or short landing zones remains to be seen. Open surgery to date is the gold standard for reconstructions involving the ascending aorta and the arch vessels. In experienced hands, the hybrid approach with open arch debranching has shown to be effective, with outcomes comparable to open reconstructions, in spite of the fact that most of the patients reported were higher risk and hybrid approach was often opted for patients who were not suitable total open repair candidates and were neither suitable for total endovascular repair. Based on our review of contemporary data from hybrid aortic reconstructions and of open reconstructions, we currently pursue a flexible approach with application of a combination of open and endovascular techniques to approach the ascending aortic and aortic arch pathologies when feasible. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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