TheThe 　　 assessmentassessment 　　 ofof 　　 thethe 　　 newnew 　　 hybridhybrid 　　procedureprocedure 　　 forfor 　　 extensiveextensive 　　 aorticaortic 　　 aneurysmsaneurysms 　　comparedcompared 　　 withwith 　　 thethe 　　 conventional　open　surgeryconventional　open　surgery

Department of Cardiovascular surgery , Osaka University Graduate School of Medicine, Osaka,Japan#1

Department of Cardiovascular surgery, Osaka General Medical Center#2

Depertment of Cardiovascular Surgery, Higashi Takarazuka Satoh Hospital#3

Keiwa Kin#1, Toru Kuratani#1, Yukitoshi Shirakawa#1, Kei Torikai#1, Kazuo Shimamura#1, Hiroshi Takano#2 , Hisashi Satoh#3 , Yoshiki Sawa#1

Procedure　for　extensive　thoracic　aortic　Procedure　for　extensive　thoracic　aortic　aneurysmaneurysm

Second　stage　repairSecond　stage　repair　　with　left　thoracotomy　with　left　thoracotomy　

•Second stage repair was not done in 43 (35.9%) of 117 patients who completed first-stage elephant trunk procedures

•Among these patients, within an average period of 3.4 years , 13 of 43 (30.2%) died, 4 of 13 (30.8%) as the result of rupture.

Safi.H.J.et.al Circulation. 2001 Dec 11;104(24):2938-42.

Our result with elephant trunk procedure (~2000)

11 cases

Three　cases　　died　from　Three　cases　　died　from　aneurysm　rupture　aneurysm　rupture　during　the　interval　between　operationduring　the　interval　between　operation

Two-stage　repairTwo-stage　repair　　with　TEVAR　(~2002)with　TEVAR　(~2002)

Trying for　　less　invasive　procedureless　invasive　procedure

Bilateral　anterior　thoracotomy　Bilateral　anterior　thoracotomy　

•Mechanical ventilator support for more than 72h was required in 50%　of the operative survivors, and 13%　a tracheostomy was necessary.

Kouchoukos.J.et.al Ann Thorac Surg. 2007 83;811-4.

1　days　after1　days　afterTwo-stage　TEVAR(minimum overlap length 5cm)

New　hybrid　procedure　for　extensive　aortic　arch　aneurysmNew　hybrid　procedure　for　extensive　aortic　arch　aneurysm

Stent　graftStent　graft

Under　DHCAUnder　DHCA•Insertion　of　stent　graft　to　the　descending　aortaInsertion　of　stent　graft　to　the　descending　aorta•Open　distal　　anastomosisOpen　distal　　anastomosis

ObjectiveObjective

W e elucidate the efficacy of this “ hybrid procedure” to compare with a conventional single-stage repair.

　 n %

Age (y) 66.9± 12.2Male/female 96/35Pathology　　　 degenerative / dissection 77/54ComorbidityHypertension 86 61Ischemic heart disease 27 21Diabetes 27 21Renal dysfunction (Cr>1.5) 13 10Pulmonary dysfunction 17 13

2000.1~2011.10 　Elective　patients　with　extended　aortic　arch　aneurysm

131cases

Patient　sPatient　s

2000.1~2011.10 　Elective　patients　with　extended　aortic　arch　aneurysm

131cases

Patient　sPatient　s

Hybrid procedure with TEVAR

(H-group)

Single-stage procedure with cram-shell approach

(S-group)

63 cases

68 cases

　 H-group S-group

Number 63 68 n.s.

Age (y) 66.7±10.4 70.5±10.4 n.s.

Male/female 50/13 46/22 n.s.

Pathology

degenerative / dissection 37/26 40/28 n.s.

Comorbidity

Hypertension 42 44 n.s.

Ischemic heart disease 13 14 n.s.

Diabetes 12 15 n.s.

Renal dysfunction (Cr>1.5) 7 6 n.s.

Pulmonary dysfunction 10 7 n.s.

Patient　s　Patient　s　DemographicsDemographics

Hospital mortality Complication　　　 Stroke　　　 Paraplesia　　　 Acute renal failure　　　 Tracheostomy　　　

H-groupN=63

1 (1.6%)

2 (3.2%)1 (1.6%)1 (1.6%)3 (4.8%)

S-groupN=68

10 (15%)

3 (4.4%)2 (2.9%)2 (2.9%)14 (21%)

　　　　　　　　　　　　　　Short-term　RESULTSShort-term　RESULTS

0.0068

0.71190.60480.60480.0071

Mid-term　RESULTMid-term　RESULT~mortality~~mortality~Mid-term　RESULTMid-term　RESULT~mortality~~mortality~ Follow-up: 32.0month (1-

121) Follow-up completion: 97.1%

0

.2

.4

.6

.8

1

0 20 40 60 80 100 120 140Number at riskOver-all 131 　 57 23 11 5H-group 63 36 13 　　　 7 　　　　 3S-group 68 21 10 　　　 4 　　　 2

Free　from　aneurysm-related　mortality(4 years; 86% H-group vs 71% S-group P= .0262)

ConclusionConclusion

Hybrid procedure with frozen elephant trunk and TEVAR gave excellent early and long-term results compared with a conventional single-stage repair.

This hybrid procedure may be alternative to the conventional sigle-stage.