Complex Thoracic and Abdominal Aortic Repair Using Hybrid Techniques
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1 Complex Thoracic and Abdominal Aortic Repair Using Hybrid Techniques Tariq Almerey MD, January Moore BA, Houssam Farres MD, Richard Agnew MD, W. Andrew Oldenburg MD, Albert Hakaim MD Department of Vascular Surgery Mayo Clinic, Florida Florida Vascular Society 30th Annual Scientific Sessions May 7, MFMER slide-1
2 Nothing to disclose 2016 MFMER slide-2
3 Background Prevalence of aortic disease increases with age Increased oxidative stress Increased loss of vascular smooth muscle Endothelial dysfunction Acute aortic disease includes aneurysm, dissection, penetrating ulcer and intramural hemorrhage Dai et al. J Geriatric Cardiology 2015;12: MFMER slide-3
4 Background Aortic aneurysm - Primary cause of 9,863 deaths in Ruptured aneurysm has a high mortality rate regardless of the aneurysm location rtic_aneurysm.htm 2016 MFMER slide-4
5 Background Aortic dissection Incidence is per 100,000 personyears Tends to occur primarily in men years Bickerstaff LK et al. Surgery Dec;92(6): Mészáros I. Chest. 2000;117(5):1271 Clouse WD et al. Mayo Clin Proc. 2004;79(2): MFMER slide-5
6 Background Open repair of aortic aneurysm has historically high rates of morbidity and mortality Hybrid repair techniques have been increasingly used as an alternative to open aneurysmal repair since it was first described by Quinones-Baldrich in 1999 Cowan et al. J Vascular Surg June; Czerny et al. Ann Cardiothoracic Surg. 2013;2(3): Ham et al. J Vascular Surg. 2011;54(1):30-41 Quinones-Baldrich et al. J Vasc Surg. 1999;30(3): MFMER slide-6
7 Background Hybrid surgical repair of aortic conditions like aneurysm involves debranching of the aortic arch and/or of the visceral or renal vessels, followed by endovascular repair 2016 MFMER slide-7
8 Background Appeal of the hybrid approach Avoidance of pleural cavity invasion, hypothermic cardiac and circulatory arrest Decreased aortic cross-clamping Hybrid techniques have shown variable success when compared with open repair Chiesa et al. Multimed Man Cardiothoracic Surg. 2014:1-8 Damrauer and Fairman. Aorta (Stamford). 2015;3(2): MFMER slide-8
9 Objective Patient outcomes after hybrid openendovascular aortic repair at our institution are reported and analyzed Retrospective study from June October MFMER slide-9
10 Methods 24 patients with complex aortic disease underwent hybrid repair procedures One patient was excluded due to device malfunction that resulted in death Demographics, comorbidities, disease presentation, intraoperative characteristics and post-operative outcomes were collected from medical records 2016 MFMER slide-10
11 Case 1 A 78 year-old male with known thoracic and abdominal aortic aneurysm presents with: Chest pressure sensation Hoarseness Constant fatigue Productive cough Vascular risk factors: Active smoker (60 packs/yr), HTN, HLD 2016 MFMER slide-11
12 Case MFMER slide-12
13 Case MFMER slide-13
14 Case 2 A 67 year-old African American male presented to the ED with symptomatic type A aortic dissection No prior cardiac or vascular procedures Vascular risk factors: HTN, HLD, and smoking 2016 MFMER slide-14
15 Case MFMER slide-15
16 Case MFMER slide-16
17 Case MFMER slide-17
18 Case MFMER slide-18
19 Demographics Median age was 71 with ASA scores of 3 (30.4%) or 4 (69.6%) Variable Total, n=23 Age, years 71 (35-81) White race 19 (82.6%) Male 12 (52.2%) BMI 26.5 ± 5.0 ASA score -ASA 3 -ASA 4 Smoking status -Current -Past 10 years -None/none in 10 years 7 (30.4%) 16 (69.6%) 4 (17.4%) 4 (17.4%) 15 (65.2%) 2016 MFMER slide-19
20 Comorbidities Variable Total, n=23 COPD 3 (13.0%) Hypertension 18 (78.3%) Hyperlipidemia 13 (56.5%) Renal disease 7 (30.4%) Coronary artery disease 6 (26.1%) Congestive heart failure 5 (21.7%) 82.6% of patients suffered from more than one of the specified comorbidities Diabetes mellitus (Type 2) 2 (8.7%) Prior aortic procedure 2 (8.7%) Stroke history 1 (4.3%) Connective disorder (Marfan) 1 (4.3%) 2016 MFMER slide-20
21 Operative Characteristics Variable Total, n=23 Dissection 5 (21.7%) Aneurysm diameter 5.4 ( ) Emergent surgery 1 (4.3%) Staged surgery 5 (21.7%) Days between stages 422 (6-608) Debranching regions -Thoracic only -Visceral only -Thoracic & visceral 18 (81.8%) 2 (9.1%) 3 (13.6%) 21.7% of patients presented with dissection Median aneurysm diameter was 5.4 cm 81.8% of patients underwent thoracic debranching 2016 MFMER slide-21
22 Operative Characteristics Variable Total, n=23 Ascending aorta replaced (n=19) 16 (72.7%) Subclavian revascularization (n=20) 18 (90.0%) Spinal drain 14 (60.9%) Deep hypothermic circulatory arrest 3 (13.0%) Surgery on CPB 17 (73.9%) CPB time, min. 181 ± 45 Aortic clamping time, min. 114 (65-136) Operative time, min. 560 ( ) Contrast volume, ml 110 (60-160) 72.7% of patients had ascending aorta replacement 10.0% of patients did not have subclavian revascularization 60.9% of patients required a spinal drain 2016 MFMER slide-22
23 Operative Characteristics Variable Total, n=23 Ascending aorta replaced (n=19) 16 (72.7%) Subclavian revascularization (n=20) 18 (90.0%) Spinal drain 14 (60.9%) Deep hypothermic circulatory arrest 3 (13.0%) Surgery on CPB 17 (73.9%) CPB time, min. 181 ± 45 Aortic clamping time, min. 114 (65-136) Operative time, min. 560 ( ) Contrast volume, ml 110 (60-160) 73.9% of patients required CPB Mean CPB time was 181 ± 45 minutes Median aortic clamp time was 114 minutes (IQR minutes) 2016 MFMER slide-23
24 Results Post-Operative Characteristics Median follow up was over 7 months Variable Total, n=23 ICU stay, days 4.5 (4-7.5) Ventilation >24 hours 8.0 (34.8%) Length of stay, days 11.5 (8-17) Follow up duration, days 218 ( ) 6-month survival (n=19) 15 (78.9%) 1-year survival (n=16) 12 (75.0%) Almost 80% of patients survived at least six months after surgery 75% of patients survived at least one year 2016 MFMER slide-24
25 Results Post-Operative Outcomes Variable Total, n=23 Visceral ischemia 0 (0%) Spinal cord injury 0 (0%) Renal failure (requiring CRRT) 1 (4.3%) Acute kidney injury (resolved) 3 (13.0%) Stroke -Major* -Minor (No long term sequelae) 1 (4.3%) 2 (8.7%) Stent graft endoleak (all Type 2) 4 (17.4%) Retrograde dissection 1 (4.3%) Graft patency (n=20) 20 (100%) Reintervention 2 (8.7%) Extremity amputation 0 (0%) 30-day mortality 3 (13.0%) One patient suffered renal failure, while three had AKI Stroke occurred in three patients, one major Three deaths occurred in the first 30 days after surgery *Defined as new assisted living requirements due to stroke-induced disability MFMER slide-25
26 Conclusions Open repair for complex aortic disease carries a high mortality and morbidity Hybrid repair provides a good alternative to open repair in: High risk patients Disease not amendable exclusively by endovascular repair 2016 MFMER slide-26
27 Questions & Discussion 2016 MFMER slide-27
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