|Year : 2022 | Volume
| Issue : 2 | Page : 203-205
Hybrid procedures for thoracoabdominal aortic aneurysms: a feasible and cost-effective alternative
Tom Thomas Kattoor, Harishankar Ramachandran Nair, Ashutosh Kumar Pandey, P M Vineeth Kumar, Shivanesan Pitchai
Department of CTVS, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
|Date of Submission||01-Sep-2021|
|Date of Acceptance||22-Dec-2021|
|Date of Web Publication||13-Jun-2022|
Department of CTVS, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala
Source of Support: None, Conflict of Interest: None
The surgical repair of thoracoabdominal aortic aneurysm (TAAA) remains one of the most technically demanding surgical procedures in vascular surgery. High-volume centers still have significant morbidity and mortality rates of 12%–15%. Emergence of thoracic endovascular aneurysm repair (TEVAR) improved these figures but was limited by the availability of customized grafts and cost factors. An effective alternative approach hence is a hybrid procedure that involves the combination of open technique for debranching of viscerorenal aorta and use of standard TEVAR stent graft to cover aneurysmal segment. We report a case of an elderly male who underwent a successful staged Hybrid TEVAR procedure for Type 3 equivalent TAAA.
Keywords: Hybrid thoracic endovascular aneurysm repair, thoracic endovascular aneurysm repair, thoracoabdominal aortic aneurysm
|How to cite this article:|
Kattoor TT, Nair HR, Pandey AK, Kumar P M, Pitchai S. Hybrid procedures for thoracoabdominal aortic aneurysms: a feasible and cost-effective alternative. Indian J Vasc Endovasc Surg 2022;9:203-5
|How to cite this URL:|
Kattoor TT, Nair HR, Pandey AK, Kumar P M, Pitchai S. Hybrid procedures for thoracoabdominal aortic aneurysms: a feasible and cost-effective alternative. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Jul 3];9:203-5. Available from: https://www.indjvascsurg.org/text.asp?2022/9/2/203/347261
| Introduction|| |
Thoracoabdominal aortic aneurysm (TAAA) is localized or diffuse dilatations in the thoracic and abdominal aorta secondary to weakening and subsequent expansion of the aortic wall. The surgical repair of TAAA remains one of the most technically demanding surgical procedures in vascular surgery as it requires reimplantation of viscerorenal and intercostal arteries to prosthetic graft, exposure of thoracic and abdominal cavities with transection of diaphragm as well as the sheer physiologic stress of the surgery due to aortic cross-clamping and active/passive aortic shunts which can result in significant morbidity, decline in quality of life, and death.
The modern era of surgical treatment of TAAA began with Stanley Crawford, who, with his lifetime experience of over 1500 TAAAs, achieved an overall mortality of 8% and paralysis risk of 16%. High-volume centers still have significant morbidity and mortality rates of 12%–15%. Emergence of thoracic endovascular aneurysm repair (TEVAR) improved these figures but was limited by the availability of customized grafts and cost factors. An effective alternative approach hence is a hybrid procedure that involves a combination of open technique for debranching of viscerorenal aorta and use of standard TEVAR stent graft to cover aneurysmal segment. This was first described in 1999 by Quinones-Baldrich et al. We report a case of an elderly male who underwent a successful staged hybrid TEVAR procedure for Type 3 equivalent TAAA.
| Case Report|| |
A 75-year-old male presented to the outpatient department with abdominal pain, radiating to back with no postprandial aggravation. He had a history of left-hemispheric stroke (recovered) in the past and was a reformed smoker. He was a known case of coronary artery disease (double vessel disease) status post stenting 5 months back. He was hemodynamically stable, but his pedal pulses were absent. Abdominal examination revealed a palpable, nontender, 6 cm wide aneurysm. Computed tomographic aortogram [Figure 1] showed Type III equivalent TAAA with a maximum diameter of 6.5 cm with a relatively normal viscerorenal segment and 7 cm juxtarenal aortic aneurysm. The left common iliac artery (CIA) was aneurysmal and the right CIA was heavily calcific.
|Figure 1: Oblique sagittal view of computed tomographic aortogram showing Type III equivalent thoracoabdominal aortic aneurysm with maximum diameter 6.5 cm (1) with a relatively normal viscerorenal segment (2) and 7cm juxtarenal aortic aneurysm and diseased iliac arteries (3)|
Click here to view
Considering his comorbidities and heavily diseased bilateral CIA, he was advised for TEVAR with fenestration for the viscerorenal vessels and coverage up to the b/l CIA. However, the overall cost of the procedure was high; he could afford it. Hence, he was planned for a two-stage procedure – repair of abdominal part of aneurysm (endoaneurysmorrhaphy with pan viscerorenal debranching) followed by TEVAR for proximal component – distal DTA aneurysm which had two advantages. First morbidity is less compared to standard open repair of TAAA and second, the cost can be reduced.
| Procedure|| |
Aneurysm was approached transperitoneally under general anesthesia. Renal arteries, bilateral CIA, superior mesenteric artery (SMA), and celiac stump were identified, dissected, and looped. Right proximal CIA was aneurysmal and left CIA and EIA were heavily calcific. Proximal suprarenal clamp applied after heparinization and distally clamping iliac arteries. Aneurysm was opened, thrombus evacuated, and renoplegia solution was administered through both renal arteries. Proximal end of 16 mm × 8 mm coated polyester graft was sutured at the neck and the Y limbs anastomosed to right CIA and left common femoral artery [Figure 2]. Inferior mesenteric artery was reimplanted end to side onto the body of graft. A new 12 mm × 6 mm graft was taken and body was anastomosed to distal end of the main graft and its limbs were anastomosed to the common hepatic artery and right renal artery. The 6 mm polyester grafts were benched to the side of graft body and anastomosed to the SMA and left renal artery. The proximal part of the bypassed vessels was ligated to prevent future type 2 endoleak after TEVAR. He tolerated the procedure well and was shifted to the intensive care unit for monitoring.
|Figure 2: Intraoperative picture showing (1) Infrarenal aorta replaced with 16 × 8 bifurcated polyester graft and bypasses to (2) Superior mesenteric artery (3) Left renal artery (4) Common hepatic artery (5) Right renal artery and (6) Right common iliac artery (7) Left common femoral artery|
Click here to view
Postoperatively, the patient had elevated renal parameters and liver enzymes, both of which subsided with conservative management. He was discharged on the 8th postoperative day. He underwent staged TEVAR after 1 month. COOK ZENITH ALPHA 36 mm × 200 mm stent graft with a proximal aortic extender 36 mm × 70 mm stent graft were used. Postoperative period was uneventful with no focal neurological deficits (lumbar spinal drain which was inserted during TEVAR was removed after 24 h), and the patient was discharged after 3 days. He is doing well after 1 year of follow-up. Follow-up scan shows patent bypass grafts with no evidence of endoleak [Figure 3].
|Figure 3: (a and b) 3D reconstruction after pan viscerorenal debranching. (1) Aortic graft, bypasses to (2) Superior mesenteric artery (3) Left renal artery (4) Left common femoral artery (5) Right external iliac artery (6) Right renal artery (7) Common hepatic artery and (8) Thoracic endovascular aneurysm repair stent graft|
Click here to view
| Discussion|| |
Although hybrid approach is not minimally invasive, it definitely is less invasive, carrying significantly less morbidity when compared to traditional open repair. It also proposes many theoretical advantages, namely no need for thoracotomy; intact diaphragm; and no need for left heart bypass, hence reducing associated profound physiological derangements. In 2009, Quinones-Baldrich et al. reported follow-up of their first patient who was doing well without any reintervention and their overall results of 20 cases. Three patients underwent hybrid procedures for aortic arch pathology and seventeen patient of thoracoabdominal and juxtarenal aortic aneurysms, they reported nine major complications in six patients (32%), one case of permanent paraplegia (out of 15 patients at risk, 6.6%), and no perioperative mortality. With a mean of 16 months, they identified three endoleaks (30%, one type I, three type II) and no bypass thrombosis. Hughes et al. reported a case series of 58 patients with 9% perioperative mortality and 4% permanent paraplegia. However, there was no paraplegia in 25 patients who underwent staged repair. These patients also had shorter combined operative time, decreased transfusion, and were extubated in <24 h. Follow-up of 26 months showed 95% graft patency. However, Patel et al. reported 4.3% permanent paraplegia and 26% inhospital mortality rate. These were 23 high-risk individuals who were not candidates for open repair like our index patient. Staging of repair is preferred over doing both the procedures as the same time because it allows time for recovery from the procedure. The staging at two separate dates is feasible in elective surgery like our index case, but in emergencies, we may have to proceed with stent grafting immediately after debranching.
| Conclusion|| |
Current literature on hybrid procedures allows high-risk patients to have almost similar outcomes as open repair in fit patients. Morbidity, although present, is considerably lesser than conventional open repair. Staging of TEVAR provides adequate time for the patient to recuperate from the initial open procedure. It also avoids extensive coverage of aortic segment and also the need for multiple fenestrations/parallel grafts for the viscerorenal arteries. Hybrid TEVAR sure is a feasible alternative in selected patients who is unfit for conventional open surgical repair of thoracoabdominal aortic aneurysms.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg 1993;17:357-68.
Guillou M, Bianchini A, Sobocinski J, Maurel B, D'elia P, Tyrrell M, et al.
Endovascular treatment of thoracoabdominal aortic aneurysms. J Vasc Surg 2012;56:65-73.
Quinones-Baldrich W, Jimenez JC, DeRubertis B, Moore WS. Combined endovascular and surgical approach (CESA) to thoracoabdominal aortic pathology: A 10 year experience. J Vasc Surg 2009;49:1125-34.
Hughes GC, Andersen ND, Hanna JM, McCann RL. Thoracoabdominal aortic aneurysm: Hybrid repair outcomes. Ann Cardiothorac Surg 2012;1:311-9.
Patel R, Conrad MF, Paruchuri V, Kwolek CJ, Chung TK, Cambria RP. Thoracoabdominal aneurysm repair: Hybrid versus open repair. J Vasc Surg 2009;50:15-22.
[Figure 1], [Figure 2], [Figure 3]