Hybrid Surgery for Aortic Diseases

George Economopoulos,MD,FACS

DISCLOSURES

NONE

WHAT is a “HYBRID” PROCEDURE ?

A combination of endoluminal and open surgical techniques at the sametime aiming to reduce the morbidity associated with a completely “open”surgical procedure

What was the standard for extensive aneurysmal aortic disease till recently?

Standard technique included:- DHCA- Elaborate methods to protect vital organs

( brain, heart, kidneys, spinal cord etc)- Bleeding problems, from hard to reach sites

And was associated with

High CVA risk (up to 20%)Reccurent nerve and Respiratory riskBleeding and CoagulopathyKidney and spinal cord injury riskMortality up to 15%Long hospital stay($$$$$)

Everything started with an elephant !

What was the ultimate strategy of the procedure?

1. Treat the proximal aortic pathology first (Ao Root, Asc Aorta , Arch)and introduce a piece of tubular graft in the beginning of the DAduring the procedure

2. At a second stage anastomose a graft in the trunk (elephant trunk)hanging inside the DA with another graft

L Swenson

Did the “Elephant trunk” procedure achieved the sought afterimprovements in mortality,morbidity , and associatedcomplications ?

“To a man with a hammer everything lookslike a nail”Mark Twain

Since the high interval mortality , the combined overall mortality and problemswith ET deployment the concept of “Frozen ET “ (FET) was introduced in 1990(Kato)

A procedure combining the concept of a prosthesis in the DA from the“traditional” ET procedure and the concept of fixing it from the TEVARtechnology in one stage ,with the stented prosthesis increasing the “sealing”effect, acting as a distal anastomosis

AORTIC ARCH DEBRANCHING PROCEDURES

AIM: To apply aortic arch procedures to patients not previously deemedcandidates due to serious comorbidities

HOW: Avoid CPB, Hypothermia, aortic clamping

Endovascular prosthesis in the Aortic arch requires an adequate “landing” zonein the aortic arch and have to take account a) the supraaortic vessels and b) theanatomic and hemodynamic properties of that part of the aorta ( curvature, highflow velosity and the significant movement of that part of the aorta with eachheart beat)

Proposal Aortic De-branching plus Arch stents

Rerouting blood flow to the supra-aortic vessels prior to stent graftdeployment by transposition or bypass techniques

16% Endoleaks !

SOME USEFUL AND IMPORTANT FACTS

1. NO Randomized controlled trial has been performed comparing thesetechniques2. The FET technique cannot be considered a single stage technique sincesubsequent interventions are required in the majority of patients ( endoleaks,other stents)3. FET has a higher incidence of SCI vs the traditional ET4. Major concern with Aortic De-branching are the endo-leaks (16%) and longterm durability and survival results are lacking

SO

ENDOVASCULAR TREATMENT OF COMPLEX AORTIC DISEASE REQUIRESSTRICT FOLLOW UP AND UNTIL ITS LONG TERM DURABILITY ISCONFIRMED,EXTENSION OF ITS APPLICATION TO GOOD SURGICALCANDIDATES MAY EVEN SEEM HAZARDOUS

THANK YOU!

Why do we want to do ARCH Hybrid procedures instead of classic open procedures?

1 Classic open Txs has serious disadvantages

a High CVA risk (20%)b Recurrent Nerve and Respiratory riskc Bleeding at posterior suture lines(difficult to control)d Eliminates DHCA and often CPB completelye Eliminates second stage mortality and Interval death rate

2Not because of the proximal Ascending / Arch component

3Hybrid procedures provide us the ability to offer a tailoredrepair to patients with complex aortic pathology