Infrarenal Aortic Repair With or Without False Lumen Intentional Placement of Endografts for Hybrid Management of Complex Aortic Pathology
William J. Quinones-Baldrich, M.D., Taimur Saleem, Adam Oskowitz.
UCLA Med Ctr, Dept of Surgery, Los Angeles, CA, USA.
OBJECTIVE: Thoracoabdominal aortic aneurysms (TAAA) and aortic dissection (AD) often involve the infrarenal aorta. We review our experience with infrarenal aortic repair as part of a hybrid strategy to treat complex aortic pathology. METHODS: A prospectively maintained database of patients undergoing intervention for TAAA and/or AD was reviewed. Diagnosis, imaging features, nature of the infrarenal repair (one versus two stage), endoleak, need for additional interventions, morbidity and mortality was collected. RESULTS: Between 2006 and 2016, 21 patients with TAAA underwent open infrarenal aortic repair or replacement combined with endovascular repair in a single multiple stage procedure. Fourteen patients also had AD.. In 36% of the patients with AD, the infrarenal replacement surgical graft created a distal seal zone allowing false lumen intentional placement (FLIP) of an endograft to treat the proximal AD. In one of these patients, the true lumen continues to perfuse intercostal arteries and in another, intercostal arteries originating in the false lumen distal to the end of the endograft are preserved. Fourteen cases were completed in 2 or more stages. Three patients had infrarenal aortic replacement with debranching only. Operative mortality was 4.8% (table 1). Patients were followed from 3 months to 7 years. Three patients have stable type 2 endoleaks and one patient required subsequent replacement of ascending aortic arch for aneurysmal disease. Two patients died of unrelated cause. CONCLUSIONS: Infrarenal aortic repair for treatment of TAAA and AD can be performed with low morbidity, mortality, and excellent medium term results. In patients with AD, this strategy can resolve malperfusion while simultaneously creating a landing zone using the false lumen as the conduit for the stent graft (FLIP)which allows full expansion of the endograft, potential preservation of lumbar/intercostal artery flow and exclusion of the weaker false lumen.
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