Combined Endovascular and Surgical Repair of Thoracoabdominal Aortic Pathology: Hybrid TEVAR

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Combined Endovascular and Surgical Repair of Thoracoabdominal Aortic Pathology: Hybrid TEVAR William J. Quinones-Baldrich MD Professor of Surgery Director UCLA Aortic Center UCLA Medical Center Los Angeles, California

Disclosures Speaker / consultant W.L. Gore Endologix Medtronic

Hybrid Approach to Aortic Pathology Surgical component -Debranching of visceral or extracranial vessels - Other Endovascular component - Adequate seal zone either present or created Rationale Decrease magnitude of procedure No thoracotomy required No high aortic cross-clamping required Ischemia time of each visceral organ limited to time required to do distal anastomosis; simultaneous ischemia to all visceral organs avoided Can be staged

Hybrid Approach to Thoraco-abdominal Pathology: Results 17 series with 10 or more patients as of 2011 (most considered unsuitable for open repair) Mortality 0 to 31 % ; 14% average Morbidity 30 % Paraplegia 5 % Cardiac complications 5 % Renal insufficiency / failure 12 % Results have lead some to recommend as preferred approach and others to consider it a poor option Poor choice for ruptures or emergency repair Interval aneurysm rupture is a risk

1998-2014 51 high risk patients 40 TAA 8 II, 23 III, 9 IV 5.8 % mortality - 2 interval aneurysm ruptures Paraplegia 2/40 at risk (5 %); II,III 1/31 (3.2%) 2/8 (25%) Single Stage ; 1/32 (3%) Two Stage

Staged Approach. Expanded!

Staging Decreases Risk

Staged retroperitoneal debranching, endovascular repair of type III TAA; observation of proximal DTA: Stage 1: Ilio celiac, SMA, L renal bypass Stage 2: R ilio-renal bypass, conduit, TEVAR

Staged retroperitoneal debranching, endovascular repair of type III TAA; observation of proximal DTA: Stage 1: Ilio celiac, SMA, L renal bypass Stage 2: R ilio-renal bypass, conduit, TEVAR

Type A D s/p Arch, Elephant trunk and TEVAR: Reversed Hybrid

Infrarenal Aortic Replacement as Part of Debranching Pledgeted proximal anastomosis Graft size to match available endograft May require distal tapering

Lumbar/Sacral artery revascularization

Lumbar/Sacral artery revascularization

Subcutaneous Conduit: Two stage approach Conduit passed through retrocolic tunnel Closure of peritoneum

Combined Endovascular and Surgical Approach to Thoraco-abdominal Pathology: Conduit placement (1rst stage) and thrombectomy (2 nd stage)

Chronic Dissection = Thick restrictive septum

False lumen is where aneurysm forms after dissection

51 y/o woman Known Type B aortic dissection s/p left thoracotomy and descending thoracic aortic repair on L heart bypass Radiation therapy L breast for cancer Presented with left chest and back pain Renovascular HTN Pulmonary fibrosis

Hybrid repair for type B dissection with False Lumen Intentional Placement (FLIP)

Type B Dissection with proximal DTA Aneurysm significant hypertension and LLE claudication

FLIP Intravascular Ultrasound

Type B Dissection with proximal DTA Aneurysm and renal malperfusion and LLE claudication: Hybrid TEVAR w FLIP

FLIP From false lumen to true lumen

FLIP Preservation of intercostal flow

FLIP: Anatomic Requirements Proximal landing zone in the true lumen Proximal undissected aorta Proximal surgical or endovascular graft Elephant trunk Access from the false lumen to the true lumen Proximal tear Distal landing zone Distal false lumen (staged repair) Infra-renal graft with retrograde de-branch

Infrarenal Aortic Repair With or Without False Lumen Intentional Placement (FLIP) of Endografts for Hybrid Management of Complex Aortic Pathology Between 2006 and 2016, 27 patients with TAAA underwent open infrarenal aortic replacement combined with endovascular repair in a single or multiple stage procedure 16 patients (59% ) also had AD Transient spinal cord ischemia occurred in 3 patients (11%) ; All 1 stage procedures. Peri-operative mortality was 3.7% One patient died due to interval rupture

Infrarenal Aortic Replacement and Abdominal Debranching for Aortic Dissection 16 patients with type A or B aortic dissection 15 chronic; 1 sub-acute 8 with Juxta or infrarenal AAA 13 with proximal DTA aneurysm 5 malperfusion 10 done in 2 or more stages 5 False lumen Intentional placement of endograft (FLIP) 3 have not required proximal repair Decompression of false lumen?

False Lumen Intentional Deployment (FLIP) for Endovascular Repair of Aortic Dissection Allows full expansion of endograft Improves distal perfusion May preserve intercostal / lumbar flow Excludes weaker false lumen IVUS / Trans esophageal echo is critical Limited Experience F/U to determine if behavior of false lumen is altered (Decompression?)

Durable?

Durable? Combined Endovascular and Surgical Approach (CESA or Hybrid Approach) 13 yr follow up

Durable Combined Endovascular and Surgical Approach (CESA or Hybrid Approach) 19 yr follow up

Combined Endovascular and Surgical Repair of Thoracoabdominal Aortic Pathology: Hybrid TEVAR Open surgery and endovascular alternatives are complementary Patient selection is critical Hybrid repair of aortic pathology should be in the armamentarium of all caring for patients with aortic pathology

UCLA Aortic Center Thank you aorticcenter.ucla.edu 310-AORTAFIX (310-267-8234)

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