State of Art Hybrid Approach
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1 State of Art Hybrid Approach for Complex Aorta Diseases Won Ho Kim, MD Division of Cardiology, Eulji University Hospital Eulji University School of Medicine, Daejeon, Korea
2 Introduction.Hybrid procedure in the modern era :.Combination of surgery & percutaneous intervention, staged by minutes, hours, or at most, days.hybrid CABG/PCI, hybrid PCI/valve, hybrid AF procedure.hybrid approach for complex aorta Dz J Am Coll Cardiol Intv 2008;1:459-68
3 Hybrid procedure for complex aorta Dz.Thoracic aortic aneurysm / dissection (TAA-D).Thoraco-abdominal aneurysm / dissection.abdominal aortic aneurysm / dissection
4 Hybrid approach in TAA & TAD.Limitation of endovascular stent grafting.goal of hybrid approach :.Maintain flow to supra aortic trunk (prevent stroke).prevent the significant morbidity, mortality associated with these complex arch pathology & surgery J Cardiovasc Surg 2010;51:807-19
5 Anatomic landing zone map.zone 0 :.Confined to the ascending aorta.necessity for achieving a proximal seal in the ascending aorta.zone 3 :.Region between Lt.CCA & DTA.Zone 4 :.Confined to DTA.Zone 1 :.Region between IA & Lt.CCA.Zone 2 :.Region between Lt.CCA & Lt.SCA J Endovasc Ther 2002;9(suppl 2):II98-105
6 Hybrid Aortic Repair.2 components :.Open surgical procedure :.Based on the extent of the arch that is involved with Dz.Allows proximal extension of SGs into the aortic arch.thoracic endovascular aortic repair (TEVAR) (or open stent graft)
7 Various surgical procedures.ascending aorta to innominate artery (IA) & Lt.CCA bypass.ascending aorta replacement with reimplantation IA & Lt.CCA.Ascending aorta replacement & graft to IA & CCA bypass.rt.cca to Lt.CCA bypass with or without Lt.CCA to LSA bypass.rt.axillofemoral bypass & Rt.CCA to Lt.CCA bypass.bilateral axilofemoral bypass & Lt.CCA to LSA bypass J Vasc Surg 2012;55:318-25
8 Proposed classification-1 (TAAD).Classified based on :.Anatomy of the lesion (extent of the lesion).suitability of the proximal & distal landing zones.type I, type II, & type III hybrid arch repairs.by Szeto W, et al. J Cardiovasc Surg 2010;51: Semin Thorac Cardiovasc Surg 2009;21:347-54
9 .Type I :.Isolated aortic arch aneurysm.brachiocephalic bypass with endovascular repair of the aortic arch.arch debranching procedure :.After debranching, exclusion of the lesion with TEVAR.Eliminating hypothermic circulatory arrest & potentially CP-bypass J Vasc Surg 2005;42:357-60
10 .Ascending aortic aneurysm with extension into distal arch.type II :.Aortic arch reconstruction with the stented -elephant trunk.surgical proximal aortic reconstruction combined with SG of the distal arch & DTA.Not aneurysmal at DTA (normal distal landing zone) Ann Thorac Surg 2007;83:S819-23
11 .Typically, SG is deployed during hypothermic arrest :.Frozen elephant trunk creation.antegrade via the open arch into the DTA.Following SG deployment :.Repair the ascending aortic aneurysm & arch.using a standard Dacron grafts Ann Thorac Surg 2007;83:S819-23
12 .Extensive TAAs with involvement of the ascending, arch, & DTA.Type III :.Elephant trunk repair with completion endovascular repair of the thoraco-abdominal aorta.typically, 2 staged procedure :.First stage, similar to that of type II repair :.Open arch surgery, or frozen elephant procedure.secondary placement of a thoracic SG Eur J Cardio Thorac Surg 2009;36:956-61
13 CT-aorta.Maximal diameter :.6.3 cm in the aortic arch.4.6 cm in the ascending aorta.4.3 cm in the DTA
14 Elephant trunk completion & CABG.8mm.14mm.8mm.Trifurcated graft.28mm
15
16 .Valiant Thoracic Stentgraft (Medtronic, Santa Rosa, California) :.Made of mm tapered diameter & 150mm length
17 Post-stent graft-ct-aorta
18 Proposed classification-2 (TAAD).Classified based on :.Whether the arch is surgically replaced or excluded with a stent-graft.type I, type II hybrid arch repairs.by Koullias GJ, et al. Ann Thorac Surg 2010;90:689-97
19 .Type I hybrid repair:.arch should be treated with surgery.sg extends treatment area by exclusion.role of TEVAR is secondary.ex) Frozen elephant trunk procedure Ann Thorac Surg 2010;90:689-97
20 .Type II hybrid repair:.arch is retained but SG excludes the arch.role of TEVAR is primary.open surgical component :.An adjunctive for revascularizing the great vessels Ann Thorac Surg 2010;90:689-97
21 Safety & efficacy (in TAA / TAD).Acceptable mortality & morbidity.higher incidence of early endovascular leaks :.High resolution at 6 months of follow-up (90%).Long term results are unknown
22 .15 studies with 463 patients.outcomes :.30-day mortality (8.3%).Stroke (4.4%).Paraplegia (3.9%).Endoleak rates (9.2%).Results compare favorably with surgery Ann Thorac Surg 2010;90:689-97
23 .N=38 (Zone 0;n=27, zone 1;n=11), follow-up of 28 months.outcomes :.Post op HD (7.9%).Paraplegia (2.7%).Stroke (13.1%).Overall 30-day mortality (23.7%) J Vasc Surg 2012;55:318-25
24 .Midterm results of a hybrid approach to DeBakey type I AD.Outcomes :.Hospital mortality (4.2%).Complete thrombosis of the residual distal FL (95.6%).Overall actuarial survival at 28 months (92.1 ± 7.9%) Ann Thorac Surg 2010;90:
25 Thoracoabdominal aneurysm-dissection.a fundamental problem in the surgery :.Extensive aortic exposure & prolonged interruption of aortic flow to the visceral branches while excluding the aneurysm itself from circulation.associated with remarkable morbidity & mortality rates Circulation. 2008;118:808-17
26 Benefit of hybrid approach.not require thoracotomy :.Fewer systematic & cardiac complications.less postoperative pain & blood loss.fewer coagulation disorders.reduced rate of spinal cord injury.reduced duration of mesenteric & visceral ischemia.reduced renal failure Ann Thorac Surg 2010;89:
27 Various surgical procedures.iliac-celiac-superior mesenteric artery (SMA) bypass.retrograde aortoceliac-sma bypass.aorto-innominate & aorto-lt.cca bypass.ascending aorta to innominate artery (IA) & Lt.CCA bypass.visceral or renal re-routing (bypass)
28 Single or staged (2 nd stage) procedure.single stage strategy :.Eliminate the risk of intersurgical aortic rupture.offer a prompt iliac or aortic access site (when femoral accesses are not adequate).two staged approach :.Reduces the burden of procedure.theoretically, reduces the risk of coagulopathy J Cardiovasc Surg (Torino) 2010;51:821-32
29 Safety & efficacy (in thoracoabdominal aortic pathology).reduce complications in the average, low risk patient.extend the indications for repair to patients considered higher risk based on age, co-morbidities, or anatomic considerations.debate high risk patients (outcomes of meta-analysis) J Am Coll Surg 2007;205:420-31
30 .Mean follow up 22 months, upto 6 years.outcomes :.30 days mortality rate (14.3%).Overall survival rate at 3 years (70%).Type I endoleak rate (8%).Permanent paraplegia rate (11%) J Vasc Surg 2008;47:724-32
31 .Mean follow up of 16.6 months (range, months) with a hybrid approach in 20 patients.outcomes :.No perioperative mortality.cumulative survival at two years (76%).Two stage approach is preferable.in high risk patients :.Acceptable morbidity & mortality J Vasc Surg 2009;49:
32 .Meta-analysis.To assess the safety & efficacy of these technique :.19 studies with a total of 507 patients.technical success, visceral graft patency, spinal cord ischemia, renal insufficiency, & 30 days mortality Circulation 2011;124:
33 (%) % 96.5%.No significant differences compared with surgery % 4.5% 0 Primary technical success Visceral graft patency 30 days mortality Paraplegia Circulation 2011;124:
34 LSA coverage during TEVAR Or
35 .Up 40% of patients undergoing TEVAR :.Pathology that extends near the LSA.Debate regarding the operative management of the LSA :.Satisfactory outcomes with intentional coverage.revascularization to reduce the incidence of complications such as stroke, paraplegia, arm ischemia J Vasc Surg 2010;51:
36 .Rec 1 :.Recommendation, but very low evidence.in elective TEVAR (coverage of LSA for SG sealing).suggest routine pre-op revascularization.rec 3 :.In urgent TEVAR (life threatening condition).suggest that revascularization should be individualized J Vasc Surg 2009;50:1155-8
37 .Rec 2 :.In anatomy that compromises perfusion to critical organ.strongly recommended routine pre-op revascularization :.Presence of a patent LIMA to CABG.Stenotic or poor developed Rt.VA.Functioning AVF in the Lt.arm (HD patient).prior infra-renal aortic repair with ligation of lumbar artery.hypogastric artery occlusion.abnormality of Lt.VA or vertebrobasilar collaterals J Vasc Surg 2009;50:1155-8
38 J Vasc Surg 2010;51:
39 .30 days-stroke or mortality (no cover, n=454 vs cover, n=279) :.Stroke rate 5.7%, mortality rate 7.0% J Vasc Surg 2011;54:979-84
40 .Post-traumatic aortic pseudo-aneurysm.left.hemothorax with multiple fib fracture
41 Modified TEVAR with chimney technique
42 SG deployment
43
44
45 Conclusion.Selection of hybrid approach :.High-risk for surgery.inadequate length of the landing zone.results compare favorably with surgery (in TAA / TAD).Debate in patients with thoracoabdominal aortic pathology.revascularization of LSA before endovascular stenting
46 Thanks yours attention
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