9th Current Trends in Aortic & Cardiovascular Surgery & Interventions
Ourania Preventza, MD Muhammad Aftab, MD Joseph S. Coselli, MD
CME Credit Presented at the 9th Current Trends in Aortic and Cardiovascular Surgery and Interventions Conference; Houston, 26–27 April 2013. Section Editor: Joseph S. Coselli, MD Key words: Aorta/pathology/surgery; aortic diseases/pathology/surgery; blood vessel prosthesis implantation; cardiac surgical procedures/methods; combined modality therapy; endovascular procedures/ methods; stents; treatment outcome; vascular surgical procedures/methods From: Department of Cardiovascular Surgery, Texas Heart Institute; and Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Houston, Texas 77030 Address for reprints: Ourania Preventza, MD, Texas Heart Institute, C-350, 6770 Bertner Ave., Houston, TX 77030 E-mail: [email protected] © 2013 by the Texas Heart ® Institute, Houston
568
Hybrid Techniques for Complex Aortic Arch Surgery
O
pen aortic arch repair can be technically demanding. The evolution of endovascular technology, the rapid adoption of various catheter-based aortic repair techniques, and the development of hybrid techniques are all steps toward avoiding the perioperative morbidity and mortality rates associated with traditional open aortic arch surgery. As the population ages, patients considered to be at too high a risk for an open repair are now treated by alternative means, such as a purely endovascular approach with custom-made devices, and “hybrid” options, such as a combination of open supra-aortic vessel debranching and the endovascular exclusion of pathologic conditions affecting the aortic arch. In June 1991, the Ukrainian surgeon Nikolay Volodos and his colleagues performed the first hybrid aortic arch repair.1 They combined open surgery for debranching of the aortic arch with stent-grafting of anastomotic dissections that remained from the patient’s previous operation for coarctation. Volodos subsequently reported that the patient was still alive in February 2013 and that the endoprosthesis was stable.2 With current technology, a purely endovascular repair of the aortic arch necessitates devices customized for each patient’s anatomy and pathologic condition. This raises questions about each device’s durability and ability to withstand increased shear forces close to the origin of the brachiocephalic vessels. Such durability can be difficult to achieve.3 The complexity of a hybrid aortic arch operation depends on the nature and extent of the aortic disease. In comparison with a single saccular aneurysm that involves only the transverse arch, many conditions require further planning for a more complex procedure. Examples include multiple saccular aneurysms that involve the ascending aorta, the arch, and the descending aorta; a chronically dissected enlarging arch with existing Dacron grafts in the ascending and descending thoracic aorta; and “megaaorta” with ascending, arch, and descending thoracic aneurysms. Different landing zones for proximal landing of the stent-graft were classified in response to the technical challenges of thoracic endovascular aortic repair (TEVAR).4 Zone 0 is in the ascending aorta, proximal to the brachiocephalic artery; zone 1 covers the portion of the arch between the brachiocephalic artery and the left common carotid artery; zone 2 covers the part of the arch between the left common carotid artery and the left subclavian artery; zone 3 covers the proximal descending thoracic aorta distal to the left subclavian artery; and zone 4 covers the mid-descending thoracic aorta. Here, we review current techniques and results of hybrid aortic arch surgery. Zone 0: Native Ascending Aorta
This repair is performed when the native ascending aorta is not aneurysmal and the pathologic condition is solely in the transverse arch, the proximal descending thoracic aorta, or both. Two examples are isolated saccular aneurysm of the arch, and arch and proximal descending thoracic aneurysm with no involvement of the ascending aorta. This repair consists of debranching the supra-aortic arch vessels, then delivering a stent—either antegrade through the ascending aorta or retrograde through the femoral artery stent-graft—into the ascending aorta to exclude the diseased portion in the aortic arch.5 The reconstruction of the arch vessels is most often performed through a median sternotomy with use of a prefabricated, bifurcated, inverted Y, or trifurcated graft; alternatively, it can be performed through an extra-anatomic bypass. The prefabricated grafts are available in different sizes, to accommodate different vessel diameters.
Hybrid Techniques for Complex Aortic Arch Surgery
Volume 40, Number 5, 2013
We have described our technique previously5: through a median sternotomy, a partial occluding clamp is applied to the ascending aorta, and the proximal anastomosis is performed with the main trunk of the bifurcated or trifurcated inverted Y-graft. We then perform the individual distal anastomoses: first to the left subclavian artery, then to the left common carotid artery, and last to the brachiocephalic artery. If the left subclavian artery is difficult to mobilize and reach through the median sternotomy, a left carotid-to-left subclavian bypass is performed through a supraclavicular incision (Fig. 1). After the bypasses to the head vessels are completed, the endovascular portion of the procedure follows. This consists of antegrade or retrograde stent-graft delivery with the proximal landing zone in the ascending aorta, to cover the diseased portion in the aortic arch (Fig. 2). The choice of antegrade or retrograde delivery is predicated on the quality of the iliofemoral vessels and the surgeon’s preference. Extra-anatomic bypass to the head vessels has been also described in patients in whom median sternotomy posed prohibitive risk.5-7
arch and the descending thoracic aorta. We are cautious about treating the entire descending thoracic aorta in the same operation. The entire procedure can be very morbid, and it poses different postoperative hemodynamic challenges with regard to spinal cord protection. Zone 0: Dilated Ascending Aorta in Patients Who Should Not Undergo Cardiopulmonary Bypass
“Aortic wrapping” has been advocated by Gelpi and colleagues.11 In our practice, when the ascending aorta’s diameter is 4 to 4.5 cm and the patient is at too high a
Zone 0: Replacement of Aneurysmal Ascending Aorta with a Dacron Graft
In this repair, the pathologic condition involves the ascending aorta and the aortic arch and might or might not affect the distal aorta. By reconstructing the aneurysmal ascending aorta with a Dacron graft, we enable the endograft to be safely deployed in zone 0 by excluding the arch and the diseased portion in the proximal descending thoracic aorta. The procedure requires cardiopulmonary bypass with circulatory arrest, with or without the use of antegrade cerebral perfusion (ACP).5,8,9 Single-stage total arch and elephant trunk (ET) repair, with sternotomy but without circulatory arrest or deep hypothermia, has been also reported.10
Fig. 1 Intraoperative angiogram shows aortic arch debranching of all head vessels and multiple saccular aneurysms of the arch. LCCA = left common carotid artery; LSCA = left subclavian artery
“Mega-Aorta”
In this repair, the pathologic condition involves extensive aneurysmal disease of the ascending aorta, aortic arch, and descending thoracic aorta. The repair is performed in a single stage or, more often, in 2 stages. In the 2-stage repair, the first stage consists of ascending aortic replacement and an ET replacement of the arch with the patient under circulatory arrest and ACP; the 2nd stage is the endovascular completion of the ET, with retrograde delivery of the stent-graft within the conventional ET up to the level of the celiac axis. To facilitate the 2nd procedure, the stent can be delivered antegrade within the Dacron graft of the trunk of the ET during the first stage (“stented” ET). In the singlestage version of the procedure, a median sternotomy is performed to achieve the repair of the ascending and the proximal and mid arch; simultaneously, under fluoroscopic guidance, a stent is delivered antegrade or retrograde up to the level of the celiac axis to repair the distal Texas Heart Institute Journal
Fig. 2 Final intraoperative angiogram shows aortic arch debranching with endovascular exclusion of all saccular arch aneurysms.
Hybrid Techniques for Complex Aortic Arch Surgery
569
risk to undergo cardiopulmonary bypass for ascending aorta replacement, we proceed with aortic wrapping for reinforcement.5 In such cases, the proximal deployment of the stent-graft is in the native ascending aorta but, in addition, a Dacron tube-graft that opens longitudinally is wrapped around the ascending aorta for reinforcement. Zone 1: Covering the Left Common Carotid Artery
This repair applies to pathologic conditions of the mid and distal arch with or without extension into the descending thoracic aorta. The steps of the repair include left carotid–subclavian bypass or transposition, followed by left carotid–right carotid artery retropharyngeal bypass and ligation of the proximal left carotid artery below the graft anastomosis. The stent-graft is then delivered retrograde to cover the distal and mid arch up to the level of the brachiocephalic artery.7,12 Cervical bypass or transposition has proved to be safe and durable in the long term,7 and it is effective for extending the proximal landing zone of the TEVAR. Occasionally, to avoid the crossover carotid–carotid bypass, a stent is deployed through the left common carotid artery as part of a snorkel technique performed simultaneously with stent arch exclusion.13 Zone 2: Covering the Left Subclavian Artery
This repair is performed in patients who have pathologic conditions of the distal arch with or without additional descending thoracic disease. The procedure consists of left carotid–subclavian artery bypass or transposition before or during retrograde stent delivery to cover the pathologic condition in the distal arch. Although coverage of the left subclavian artery with or without revascularization is controversial,4-17 the following absolute indications for revascularization of the left subclavian artery are universally accepted: a dominant left vertebral artery, an absent right vertebral artery, an incomplete vertebrobasilar system, a patent left internal mammary artery–left anterior descending coronary artery bypass, and a left arteriovenous fistula or graft for hemodialysis. Relative indications could include extensive coverage of the descending thoracic aorta to avoid spinal cord ischemia (because the anterior spinal artery is partly formed from branches of the thyrocervical trunk) and a history of arm ischemia. Outcomes
We have reported our initial, 6-year experience with using zone 0 as a landing zone in 29 high-risk patients with pathologic conditions of the aortic arch.5 The inhospital mortality rate was 6.9%. Three patients (10%) had strokes: 1 had a major stroke, and 2 had minor strokes with substantial recovery afterward. No incidence of paraplegia or retrograde dissection was noted 570
Hybrid Techniques for Complex Aortic Arch Surgery
in our series. In a report from a transcontinental registry with 5 participating centers, Czerny and colleagues 18 reported the following outcome rates in 66 patients: 30day mortality, 9%; stroke, 5%; paraplegia, 3%; and retrograde type I aortic dissection, 8%. Melissano and associates 19 reported that their 32 patients had a 9% early mortality rate, a 9% stroke rate, and no paraplegia. Direct comparisons between hybrid and conventional open arch repair are difficult and might be unfair, given the severity of comorbid conditions in patients who undergo the hybrid procedures. In all the above-mentioned series, the number of patients was relatively small, so larger studies with longer follow-up periods are needed to determine whether hybrid arch repair techniques will stand the test of time.
References 1. Volodos NL, Karpovich IP, Troyan VI, Kalashnikova YuV, Shekhanin VE, Ternyuk NE, et al. Clinical experience of the use of self-fixing synthetic prostheses for remote endoprosthetics of the thoracic and the abdominal aorta and iliac arteries through the femoral artery and as intraoperative endoprosthesis for aorta reconstruction. Vasa Suppl 1991;33:93-5. 2. Volodos NL. Historical perspective: the first steps in endovascular aortic repair: how it all began. J Endovasc Ther 2013;20 Suppl 1:I3-23. 3. Moon MC, Morales JP, Greenberg RK. The aortic arch and ascending aorta: are they within the endovascular realm [published erratum appears in Semin Vasc Surg 2007;20(3):195]? Semin Vasc Surg 2007;20(2):97-107. 4. Criado FJ, Abul-Khoudoud OR, Domer GS, McKendrick C, Zuzga M, Clark NS, et al. Endovascular repair of the thoracic aorta: lessons learned. Ann Thorac Surg 2005;80(3):857-63. 5. Preventza O, Bakaeen FG, Cervera RD, Coselli JS. Deployment of proximal thoracic endograft in zone 0 of the ascending aorta: treatment options and early outcomes for aortic arch aneurysms in a high-risk population. Eur J Cardiothorac Surg 2013;44(3):446-53. 6. Criado FJ, Barnatan MF, Rizk Y, Clark NS, Wang CF. Technical strategies to expand stent-graft applicability in the aortic arch and proximal descending thoracic aorta. J Endovasc Ther 2002;9 Suppl 2:II32-8. 7. Criado FJ, McKendrick C, Criado FR. Technical solutions for common problems in TEVAR: managing access and aortic branches. J Endovasc Ther 2009;16 Suppl 1:I63-79. 8. Weigang E, Parker J, Czerny M, Peivandi AA, Dorweiler B, Beyersdorf F, Siegenthaler MP. Endovascular aortic arch repair after aortic arch de-branching. Ann Thorac Surg 2009; 87(2):603-7. 9. Bavaria J, Milewski RK, Baker J, Moeller P, Szeto W, Pochettino A. Classic hybrid evolving approach to distal arch aneurysms: toward the zone zero solution. J Thorac Cardiovasc Surg 2010;140(6 Suppl):S77-80. 10. Kent WD, Herget EJ, Wong JK, Appoo JJ. Ascending, total arch, and descending thoracic aortic repair for acute DeBakey type I aortic dissection without circulatory arrest. Ann Thorac Surg 2012;94(3):e59-61. 11. Gelpi G, Vanelli P, Mangini A, Danna P, Contino M, Antona C. Hybrid aortic arch repair procedure: reinforcement of the aorta for a safe and durable landing zone. Eur J Vasc Endovasc Surg 2010;40(6):709-14.
Volume 40, Number 5, 2013
12. Andersen ND, Williams JB, Hanna JM, Shah AA, McCann RL, Hughes GC. Results with an algorithmic approach to hybrid repair of the aortic arch. J Vasc Surg 2013;57(3):655-67. 13. Patel RP, Katsargyris A, Verhoeven EL, Adam DJ, Hardman JA. Endovascular aortic aneurysm repair with chimney and snorkel grafts: indications, techniques and results. Cardiovasc Intervent Radiol 2013;36(6):1443-51. 14. Preventza O, Wheatley GH 3rd, Williams J, Chaugle H, Hughes K, Ramaiah V, et al. Can the left subclavian artery be safely covered during endovascular repair of the descending thoracic aorta? Innovations (Phila) 2008;3(3):147-50. 15. Woo EY, Carpenter JP, Jackson BM, Pochettino A, Bavaria JE, Szeto WY, Fairman RM. Left subclavian artery coverage during thoracic endovascular aortic repair: a single-center experience. J Vasc Surg 2008;48(3):555-60. 16. Rizvi AZ, Murad MH, Fairman RM, Erwin PJ, Montori VM. The effect of left subclavian artery coverage on morbidity and
Texas Heart Institute Journal
mortality in patients undergoing endovascular thoracic aortic interventions: a systematic review and meta-analysis. J Vasc Surg 2009;50(5):1159-69. 17. Weigang E, Parker JA, Czerny M, Lonn L, Bonser RS, Carrel TP, et al. Should intentional endovascular stent-graft coverage of the left subclavian artery be preceded by prophylactic revascularisation? Eur J Cardiothorac Surg 2011;40(4):858-68. 18. Czerny M, Weigang E, Sodeck G, Schmidli J, Antona C, Gelpi G, et al. Targeting landing zone 0 by total arch rerouting and TEVAR: midterm results of a transcontinental registry. Ann Thorac Surg 2012;94(1):84-9. 19. Melissano G, Tshomba Y, Bertoglio L, Rinaldi E, Chiesa R. Analysis of stroke after TEVAR involving the aortic arch [published erratum appears in Eur J Vasc Endovasc Surg 2012;43(5):620-1]. Eur J Vasc Endovasc Surg 2012;43(3): 269-75.
Hybrid Techniques for Complex Aortic Arch Surgery
571
Ourania Preventza, MD Muhammad Aftab, MD Joseph S. Coselli, MD
CME Credit Presented at the 9th Current Trends in Aortic and Cardiovascular Surgery and Interventions Conference; Houston, 26–27 April 2013. Section Editor: Joseph S. Coselli, MD Key words: Aorta/pathology/surgery; aortic diseases/pathology/surgery; blood vessel prosthesis implantation; cardiac surgical procedures/methods; combined modality therapy; endovascular procedures/ methods; stents; treatment outcome; vascular surgical procedures/methods From: Department of Cardiovascular Surgery, Texas Heart Institute; and Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Houston, Texas 77030 Address for reprints: Ourania Preventza, MD, Texas Heart Institute, C-350, 6770 Bertner Ave., Houston, TX 77030 E-mail: [email protected] © 2013 by the Texas Heart ® Institute, Houston
568
Hybrid Techniques for Complex Aortic Arch Surgery
O
pen aortic arch repair can be technically demanding. The evolution of endovascular technology, the rapid adoption of various catheter-based aortic repair techniques, and the development of hybrid techniques are all steps toward avoiding the perioperative morbidity and mortality rates associated with traditional open aortic arch surgery. As the population ages, patients considered to be at too high a risk for an open repair are now treated by alternative means, such as a purely endovascular approach with custom-made devices, and “hybrid” options, such as a combination of open supra-aortic vessel debranching and the endovascular exclusion of pathologic conditions affecting the aortic arch. In June 1991, the Ukrainian surgeon Nikolay Volodos and his colleagues performed the first hybrid aortic arch repair.1 They combined open surgery for debranching of the aortic arch with stent-grafting of anastomotic dissections that remained from the patient’s previous operation for coarctation. Volodos subsequently reported that the patient was still alive in February 2013 and that the endoprosthesis was stable.2 With current technology, a purely endovascular repair of the aortic arch necessitates devices customized for each patient’s anatomy and pathologic condition. This raises questions about each device’s durability and ability to withstand increased shear forces close to the origin of the brachiocephalic vessels. Such durability can be difficult to achieve.3 The complexity of a hybrid aortic arch operation depends on the nature and extent of the aortic disease. In comparison with a single saccular aneurysm that involves only the transverse arch, many conditions require further planning for a more complex procedure. Examples include multiple saccular aneurysms that involve the ascending aorta, the arch, and the descending aorta; a chronically dissected enlarging arch with existing Dacron grafts in the ascending and descending thoracic aorta; and “megaaorta” with ascending, arch, and descending thoracic aneurysms. Different landing zones for proximal landing of the stent-graft were classified in response to the technical challenges of thoracic endovascular aortic repair (TEVAR).4 Zone 0 is in the ascending aorta, proximal to the brachiocephalic artery; zone 1 covers the portion of the arch between the brachiocephalic artery and the left common carotid artery; zone 2 covers the part of the arch between the left common carotid artery and the left subclavian artery; zone 3 covers the proximal descending thoracic aorta distal to the left subclavian artery; and zone 4 covers the mid-descending thoracic aorta. Here, we review current techniques and results of hybrid aortic arch surgery. Zone 0: Native Ascending Aorta
This repair is performed when the native ascending aorta is not aneurysmal and the pathologic condition is solely in the transverse arch, the proximal descending thoracic aorta, or both. Two examples are isolated saccular aneurysm of the arch, and arch and proximal descending thoracic aneurysm with no involvement of the ascending aorta. This repair consists of debranching the supra-aortic arch vessels, then delivering a stent—either antegrade through the ascending aorta or retrograde through the femoral artery stent-graft—into the ascending aorta to exclude the diseased portion in the aortic arch.5 The reconstruction of the arch vessels is most often performed through a median sternotomy with use of a prefabricated, bifurcated, inverted Y, or trifurcated graft; alternatively, it can be performed through an extra-anatomic bypass. The prefabricated grafts are available in different sizes, to accommodate different vessel diameters.
Hybrid Techniques for Complex Aortic Arch Surgery
Volume 40, Number 5, 2013
We have described our technique previously5: through a median sternotomy, a partial occluding clamp is applied to the ascending aorta, and the proximal anastomosis is performed with the main trunk of the bifurcated or trifurcated inverted Y-graft. We then perform the individual distal anastomoses: first to the left subclavian artery, then to the left common carotid artery, and last to the brachiocephalic artery. If the left subclavian artery is difficult to mobilize and reach through the median sternotomy, a left carotid-to-left subclavian bypass is performed through a supraclavicular incision (Fig. 1). After the bypasses to the head vessels are completed, the endovascular portion of the procedure follows. This consists of antegrade or retrograde stent-graft delivery with the proximal landing zone in the ascending aorta, to cover the diseased portion in the aortic arch (Fig. 2). The choice of antegrade or retrograde delivery is predicated on the quality of the iliofemoral vessels and the surgeon’s preference. Extra-anatomic bypass to the head vessels has been also described in patients in whom median sternotomy posed prohibitive risk.5-7
arch and the descending thoracic aorta. We are cautious about treating the entire descending thoracic aorta in the same operation. The entire procedure can be very morbid, and it poses different postoperative hemodynamic challenges with regard to spinal cord protection. Zone 0: Dilated Ascending Aorta in Patients Who Should Not Undergo Cardiopulmonary Bypass
“Aortic wrapping” has been advocated by Gelpi and colleagues.11 In our practice, when the ascending aorta’s diameter is 4 to 4.5 cm and the patient is at too high a
Zone 0: Replacement of Aneurysmal Ascending Aorta with a Dacron Graft
In this repair, the pathologic condition involves the ascending aorta and the aortic arch and might or might not affect the distal aorta. By reconstructing the aneurysmal ascending aorta with a Dacron graft, we enable the endograft to be safely deployed in zone 0 by excluding the arch and the diseased portion in the proximal descending thoracic aorta. The procedure requires cardiopulmonary bypass with circulatory arrest, with or without the use of antegrade cerebral perfusion (ACP).5,8,9 Single-stage total arch and elephant trunk (ET) repair, with sternotomy but without circulatory arrest or deep hypothermia, has been also reported.10
Fig. 1 Intraoperative angiogram shows aortic arch debranching of all head vessels and multiple saccular aneurysms of the arch. LCCA = left common carotid artery; LSCA = left subclavian artery
“Mega-Aorta”
In this repair, the pathologic condition involves extensive aneurysmal disease of the ascending aorta, aortic arch, and descending thoracic aorta. The repair is performed in a single stage or, more often, in 2 stages. In the 2-stage repair, the first stage consists of ascending aortic replacement and an ET replacement of the arch with the patient under circulatory arrest and ACP; the 2nd stage is the endovascular completion of the ET, with retrograde delivery of the stent-graft within the conventional ET up to the level of the celiac axis. To facilitate the 2nd procedure, the stent can be delivered antegrade within the Dacron graft of the trunk of the ET during the first stage (“stented” ET). In the singlestage version of the procedure, a median sternotomy is performed to achieve the repair of the ascending and the proximal and mid arch; simultaneously, under fluoroscopic guidance, a stent is delivered antegrade or retrograde up to the level of the celiac axis to repair the distal Texas Heart Institute Journal
Fig. 2 Final intraoperative angiogram shows aortic arch debranching with endovascular exclusion of all saccular arch aneurysms.
Hybrid Techniques for Complex Aortic Arch Surgery
569
risk to undergo cardiopulmonary bypass for ascending aorta replacement, we proceed with aortic wrapping for reinforcement.5 In such cases, the proximal deployment of the stent-graft is in the native ascending aorta but, in addition, a Dacron tube-graft that opens longitudinally is wrapped around the ascending aorta for reinforcement. Zone 1: Covering the Left Common Carotid Artery
This repair applies to pathologic conditions of the mid and distal arch with or without extension into the descending thoracic aorta. The steps of the repair include left carotid–subclavian bypass or transposition, followed by left carotid–right carotid artery retropharyngeal bypass and ligation of the proximal left carotid artery below the graft anastomosis. The stent-graft is then delivered retrograde to cover the distal and mid arch up to the level of the brachiocephalic artery.7,12 Cervical bypass or transposition has proved to be safe and durable in the long term,7 and it is effective for extending the proximal landing zone of the TEVAR. Occasionally, to avoid the crossover carotid–carotid bypass, a stent is deployed through the left common carotid artery as part of a snorkel technique performed simultaneously with stent arch exclusion.13 Zone 2: Covering the Left Subclavian Artery
This repair is performed in patients who have pathologic conditions of the distal arch with or without additional descending thoracic disease. The procedure consists of left carotid–subclavian artery bypass or transposition before or during retrograde stent delivery to cover the pathologic condition in the distal arch. Although coverage of the left subclavian artery with or without revascularization is controversial,4-17 the following absolute indications for revascularization of the left subclavian artery are universally accepted: a dominant left vertebral artery, an absent right vertebral artery, an incomplete vertebrobasilar system, a patent left internal mammary artery–left anterior descending coronary artery bypass, and a left arteriovenous fistula or graft for hemodialysis. Relative indications could include extensive coverage of the descending thoracic aorta to avoid spinal cord ischemia (because the anterior spinal artery is partly formed from branches of the thyrocervical trunk) and a history of arm ischemia. Outcomes
We have reported our initial, 6-year experience with using zone 0 as a landing zone in 29 high-risk patients with pathologic conditions of the aortic arch.5 The inhospital mortality rate was 6.9%. Three patients (10%) had strokes: 1 had a major stroke, and 2 had minor strokes with substantial recovery afterward. No incidence of paraplegia or retrograde dissection was noted 570
Hybrid Techniques for Complex Aortic Arch Surgery
in our series. In a report from a transcontinental registry with 5 participating centers, Czerny and colleagues 18 reported the following outcome rates in 66 patients: 30day mortality, 9%; stroke, 5%; paraplegia, 3%; and retrograde type I aortic dissection, 8%. Melissano and associates 19 reported that their 32 patients had a 9% early mortality rate, a 9% stroke rate, and no paraplegia. Direct comparisons between hybrid and conventional open arch repair are difficult and might be unfair, given the severity of comorbid conditions in patients who undergo the hybrid procedures. In all the above-mentioned series, the number of patients was relatively small, so larger studies with longer follow-up periods are needed to determine whether hybrid arch repair techniques will stand the test of time.
References 1. Volodos NL, Karpovich IP, Troyan VI, Kalashnikova YuV, Shekhanin VE, Ternyuk NE, et al. Clinical experience of the use of self-fixing synthetic prostheses for remote endoprosthetics of the thoracic and the abdominal aorta and iliac arteries through the femoral artery and as intraoperative endoprosthesis for aorta reconstruction. Vasa Suppl 1991;33:93-5. 2. Volodos NL. Historical perspective: the first steps in endovascular aortic repair: how it all began. J Endovasc Ther 2013;20 Suppl 1:I3-23. 3. Moon MC, Morales JP, Greenberg RK. The aortic arch and ascending aorta: are they within the endovascular realm [published erratum appears in Semin Vasc Surg 2007;20(3):195]? Semin Vasc Surg 2007;20(2):97-107. 4. Criado FJ, Abul-Khoudoud OR, Domer GS, McKendrick C, Zuzga M, Clark NS, et al. Endovascular repair of the thoracic aorta: lessons learned. Ann Thorac Surg 2005;80(3):857-63. 5. Preventza O, Bakaeen FG, Cervera RD, Coselli JS. Deployment of proximal thoracic endograft in zone 0 of the ascending aorta: treatment options and early outcomes for aortic arch aneurysms in a high-risk population. Eur J Cardiothorac Surg 2013;44(3):446-53. 6. Criado FJ, Barnatan MF, Rizk Y, Clark NS, Wang CF. Technical strategies to expand stent-graft applicability in the aortic arch and proximal descending thoracic aorta. J Endovasc Ther 2002;9 Suppl 2:II32-8. 7. Criado FJ, McKendrick C, Criado FR. Technical solutions for common problems in TEVAR: managing access and aortic branches. J Endovasc Ther 2009;16 Suppl 1:I63-79. 8. Weigang E, Parker J, Czerny M, Peivandi AA, Dorweiler B, Beyersdorf F, Siegenthaler MP. Endovascular aortic arch repair after aortic arch de-branching. Ann Thorac Surg 2009; 87(2):603-7. 9. Bavaria J, Milewski RK, Baker J, Moeller P, Szeto W, Pochettino A. Classic hybrid evolving approach to distal arch aneurysms: toward the zone zero solution. J Thorac Cardiovasc Surg 2010;140(6 Suppl):S77-80. 10. Kent WD, Herget EJ, Wong JK, Appoo JJ. Ascending, total arch, and descending thoracic aortic repair for acute DeBakey type I aortic dissection without circulatory arrest. Ann Thorac Surg 2012;94(3):e59-61. 11. Gelpi G, Vanelli P, Mangini A, Danna P, Contino M, Antona C. Hybrid aortic arch repair procedure: reinforcement of the aorta for a safe and durable landing zone. Eur J Vasc Endovasc Surg 2010;40(6):709-14.
Volume 40, Number 5, 2013
12. Andersen ND, Williams JB, Hanna JM, Shah AA, McCann RL, Hughes GC. Results with an algorithmic approach to hybrid repair of the aortic arch. J Vasc Surg 2013;57(3):655-67. 13. Patel RP, Katsargyris A, Verhoeven EL, Adam DJ, Hardman JA. Endovascular aortic aneurysm repair with chimney and snorkel grafts: indications, techniques and results. Cardiovasc Intervent Radiol 2013;36(6):1443-51. 14. Preventza O, Wheatley GH 3rd, Williams J, Chaugle H, Hughes K, Ramaiah V, et al. Can the left subclavian artery be safely covered during endovascular repair of the descending thoracic aorta? Innovations (Phila) 2008;3(3):147-50. 15. Woo EY, Carpenter JP, Jackson BM, Pochettino A, Bavaria JE, Szeto WY, Fairman RM. Left subclavian artery coverage during thoracic endovascular aortic repair: a single-center experience. J Vasc Surg 2008;48(3):555-60. 16. Rizvi AZ, Murad MH, Fairman RM, Erwin PJ, Montori VM. The effect of left subclavian artery coverage on morbidity and
Texas Heart Institute Journal
mortality in patients undergoing endovascular thoracic aortic interventions: a systematic review and meta-analysis. J Vasc Surg 2009;50(5):1159-69. 17. Weigang E, Parker JA, Czerny M, Lonn L, Bonser RS, Carrel TP, et al. Should intentional endovascular stent-graft coverage of the left subclavian artery be preceded by prophylactic revascularisation? Eur J Cardiothorac Surg 2011;40(4):858-68. 18. Czerny M, Weigang E, Sodeck G, Schmidli J, Antona C, Gelpi G, et al. Targeting landing zone 0 by total arch rerouting and TEVAR: midterm results of a transcontinental registry. Ann Thorac Surg 2012;94(1):84-9. 19. Melissano G, Tshomba Y, Bertoglio L, Rinaldi E, Chiesa R. Analysis of stroke after TEVAR involving the aortic arch [published erratum appears in Eur J Vasc Endovasc Surg 2012;43(5):620-1]. Eur J Vasc Endovasc Surg 2012;43(3): 269-75.
Hybrid Techniques for Complex Aortic Arch Surgery
571
