Thoracoabdominal aneurysm repair: Hybrid versus open repair
Received 18 September 2008; accepted 21 December 2008.
Objective
Hybrid repair of thoracoabdominal aortic aneurysms (TAAA) may reduce morbidity and mortality in high-risk candidates for open repair. This study reviews the outcomes of hybrid TAAA repair for Crawford extent I-III TAAA in high-risk patients in comparison to patients who underwent concurrent open TAAA repair.
Methods
During the interval from June 2005 to December 2007, a total of 23 high-risk patients with TAAA (type I: 9 [39%], II: 5 [22%], and III: 9 [39%]) underwent renal and/or mesenteric debranching (11 [48%] with four vessel debranching) with subsequent placement of a thoracic stent graft; 77 patients underwent open TAAA repair (type I: 13 [17%], II: 11 [14%], III: 27 [35%], and IV: 26 [34%]) during the same interval. The primary high-risk criteria for hybrid TAAA included advanced age/poor functional status (n = 14), major pulmonary dysfunction (n = 8), and technical consideration (prior thoracic aortic aneurysm repair [n = 4] or prior thoracoabdominal aneurysm repair [n = 2] and obesity [n = 2]) with 6 patients having overlapping high-risk criteria. Composite (30-day) mortality and/or permanent paraplegia (PP) were the major study endpoints.
Results
The hybrid and open TAAA groups had (respectively) no statistical difference in mean age (76.6 vs 72.7 years), aneurysm size (6.51 vs 6.52 cm), and non-elective operation (30.4% vs 26.0%). The hybrid group had a higher mean Society for Vascular Surgery (SVS) risk score (9.1 vs 6.0; P ≤ .001), incidence of oxygen-dependent chronic obstructive pulmonary disease (COPD) (34.8% vs 2.6%; P ≤ .001), and prior thoracic (n = 4) or thoracoabdominal (n = 2) repair (26.1% vs 1.3%; P ≤ .001). Composite mortality and/or PP was doubled in the hybrid group (21.7% vs 11.7%; P = .33). The rate of any type of reoperation was higher in hybrid TAAA repair (39.1% vs 20.8%; P = .03). One year actuarial survival for both groups was comparable (hybrid, 68 ± 12%; open, 73 ± 6%). A total of 5/23 (22%) hybrid TAAA patients developed an endoleak (type I: 3/23 and type II: 2/23) with 3 requiring endovascular re-intervention. A total of 7/70 (10%) visceral/renal bypass grafts were noted to be occluded during follow-up (1 superior mesenteric artery, 1 celiac, and 5 renal). Examination of patients with an SVS risk score ≤8 (mean SVS risk score in hybrid 6.2 [n = 10] vs 5.5 [n = 68] in open; P = .27) revealed the hybrid group had a higher incidence of composite mortality and/or PP (40% vs 10.3%; P = .03).
Conclusion
Hybrid TAAA repair in high-risk patients has significant morbidity and mortality suggesting a non-interventional approach may be appropriate in many such patients. The morbidity and mortality of the hybrid TAAA repair was substantial even in lower risk patients (SVS risk score ≤8), albeit patient numbers were small. Prospective study in comparable patient risk cohorts is required to define the role of hybrid TAAA repair.
Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
Reprint requests: Richard P. Cambria, MD, Massachusetts General Hospital, Department of Vascular and Endovascular Surgery, 15 Parkman Street, WAC 440, Boston, MA 02114
Supported in part by the Harold and June Geneen Vascular Research Fund.
ABSTRACT