State of Art Hybrid Approach

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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

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

Hybrid procedure for complex aorta Dz.Thoracic aortic aneurysm / dissection (TAA-D).Thoraco-abdominal aneurysm / dissection.abdominal aortic aneurysm / dissection

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

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

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)

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

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;51:807-19 Semin Thorac Cardiovasc Surg 2009;21:347-54

.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

.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

.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

.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

CT-aorta.Maximal diameter :.6.3 cm in the aortic arch.4.6 cm in the ascending aorta.4.3 cm in the DTA

Elephant trunk completion & CABG.8mm.14mm.8mm.Trifurcated graft.28mm

.Valiant Thoracic Stentgraft (Medtronic, Santa Rosa, California) :.Made of 40-36 mm tapered diameter & 150mm length

Post-stent graft-ct-aorta

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

.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

.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

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

.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

.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

.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;90:1847-53

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

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;89:1475-81

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)

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

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

.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

.Mean follow up of 16.6 months (range, 1-119 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;49:1125-34

.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;124:2670-80

(%) 100 80 60 96.2% 96.5%.No significant differences compared with surgery 40 20 12.8% 4.5% 0 Primary technical success Visceral graft patency 30 days mortality Paraplegia Circulation 2011;124:2670-80

LSA coverage during TEVAR Or

.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;51:1329-39

.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

.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

J Vasc Surg 2010;51:1329-39

.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

.Post-traumatic aortic pseudo-aneurysm.left.hemothorax with multiple fib fracture

Modified TEVAR with chimney technique

SG deployment

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

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