Thoracic endovascular repair first for extensive aortic disease: the staged hybrid approach†.
OBJECTIVE
Repair of extensive aortic disease carries a significant risk of death and morbidity, the most feared complication being spinal cord ischaemia. Objectives of this study are to characterize patients, describe repair methods and assess feasibility and safety of hybrid staged repair for treatment of extensive aortic disease.


METHODS
From to 2001 to 2013, 22 patients underwent extensive aortic repair that included a thoracic endovascular aortic repair (TEVAR) first followed by an open completion repair extending through the visceral and infrarenal aorta for degenerative aneurysm and dissection. At the time of initial repair, all patients were deemed to be at a high risk for conventional open repair and had extensive disease. Indications for open completion included emergency failure of TEVAR (n = 3), early two-stage approach (n = 6) and delayed disease progression after TEVAR (n = 13). The median interval between stages was 6.5 months. The mean age was 56 ± 14 years, 5 patients had connective tissue disorder and the mean maximum aortic diameter was 58 ± 16 mm preoperatively.


RESULTS
There was no death or major complication after initial TEVAR, but the operative mortality rate was 9% (n = 2) after the open procedure. One of these patients died from intraoperative myocardial infarction during emergency repair, and the other had disseminated intravascular coagulation during delayed repair for disease progression after TEVAR. Other complications included paralysis in 1 (4.5%), tracheostomy in 2 (9%) and dialysis in 1 (4.5%), and there was 1 reoperation for bleeding (4.5%). The median follow-up was 37 (range 3.3-93) months and there were no late deaths. There were four late reoperations for proximal disease progression leading to Type 1 endoleak (n = 2), Type A dissection (n = 1) and root aneurysm (n = 1).


CONCLUSIONS
Use of a TEVAR-first approach in combination with a staged open repair is a safe and feasible treatment strategy for repair of extensive aortic disease. A staged hybrid approach to aortic repair in patients at high risk for total aortic replacement may limit morbidity.
The Aortic Center, Heart and Vascular Institute Cleveland Clinic, Cleveland, OH, USA.
Alessandro
A
Vivacqua
The Aortic Center, Heart and Vascular Institute Cleveland Clinic, Cleveland, OH, USA.
Jay J
JJ
Idrees
The Aortic Center, Heart and Vascular Institute Cleveland Clinic, Cleveland, OH, USA.
Douglas R
DR
Johnston
The Aortic Center, Heart and Vascular Institute Cleveland Clinic, Cleveland, OH, USA.
Edward G
EG
Soltesz
The Aortic Center, Heart and Vascular Institute Cleveland Clinic, Cleveland, OH, USA.
Lars G
LG
Svensson
The Aortic Center, Heart and Vascular Institute Cleveland Clinic, Cleveland, OH, USA roselle@ccf.org.
Eric E
EE
Roselli
D000328:Adult; D000368:Aged; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods* / Q000401:mortality; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods* / Q000401:mortality; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012189:Retrospective Studies; D016896:Treatment Outcome
Chronic dissection; Elephant trunk; Endovascular; Hybrid aortic repair; Thoraco-abdominal aneurysm