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Staged hybrid approach using proximal TEVAR and distal open repair for the treatment of extensive thoracoabdominal aortic aneurysms
William F. Johnston, MD, Gilbert R. Upchurch, Jr., M.D., Margaret C. Tracci, M.D., Kenneth J. Cherry, MD, Gorav Ailawadi, M.D., John A. Kern, M.D..
University of Virginia, Charlottesville, VA, USA.

OBJECTIVES:Repair of extent I and II thoracoabdominal aortic aneurysms (TAAAs) is associated with significant patient morbidity and mortality, while repair of more distal extent III and IV TAAAs has a lower risk of mortality and paraplegia. Therefore, we describe a novel approach using thoracic endovascular repair (TEVAR) as the index operation to convert extent I and II TAAAs to extent III and IV TAAAs amenable to later open aortic repair to minimize patient risk.
METHODS: Between July 2007 and July 2011, 9 staged hybrid operations were performed to treat 1 extent I and 8 extent II TAAAs secondary to aortic aneurysmal disease, including 6 chronic type B dissections, 2 acute type B dissections, and 1 penetrating aortic ulcer. Initially, the proximal descending thoracic aorta was repaired with TEVAR for coverage of the most proximal fenestration in cases of dissection. Carotid to subclavian artery bypass was performed in 5 patients (56%). Interval open distal aortic replacement was performed either in a short-term planned setting or for progressive dilation of the distal aortic segment. In the open repair, the proximal end of the graft was sewn directly to the distal end of the TEVAR and outer wall of the aorta.
RESULTS: Average patient age was 51.4 years and the majority male (67%). Two patients had Marfan syndrome. Post-operative complications following TEVAR included endoleaks [type IA (n=2); type II (n=2)], pleural effusion (n=2), and acute kidney injury (n=1). Endovascular re-intervention was required in 3 cases. In dissection cases, persistent filling of the false lumen was common and associated with continued distal aortic dilation. Following open graft placement, there were no major complications. In the patients with chronic dissection or penetrating ulcer, average hospital stay was 5.3 days following TEVAR and 7.4 days following open distal TAAA repair. The time from TEVAR to open repair was 332 ±339 days. Most importantly, there was no 30-day mortality or neurologic deficit after either procedure.
CONCLUSIONS:A staged hybrid approach to extent I and II TAAAs combining proximal TEVAR followed by interval open distal TAAA repair is a safe and effective alternative to traditional open repair. This approach may decrease the significant morbidity associated with single stage open extent I and II TAAA repairs and may be applicable to other TAAA etiologies.


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