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4/4/2014
1
Hybrid Repair for Aortic Pathology: A Reasonable Option in
Selected Patients
William J. Quinones-Baldrich MDProfessor of Surgery
Director UCLA Aortic CenterUCLA Medical Center
Los Angeles, California
Disclosures• Off label use will be presented• Device companies not promote or assure
safety and efficacy of off label use of their products
• Speaker/consultant W.L. GoreEndologixMedtronic
Hybrid Repair for Aortic Pathology
• Rationale: Reduce magnitude of surgical intervention
- Thoraco-abdominal aorta- Aortic Arch
• Use currently available endovascular devices• Allow treatment of complex pathology in high
risk patients
73y/o with R pelvic kidney s/p repair Type IV TAA,presents with contained visceral patch rupture
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71 y/o with severe COPD, Type II TAA, acute on chronic mesenteric ischemia and severe claudication
71 y/o with severe COPD, Type III TAA, acute on chronic mesenteric ischemia and severe claudication
Stage 1: IR Replacement, Visceral debranching, distal endograft
71 y/o with severe COPD, Type III TAA, acute on chronic mesenteric ischemia and severe claudication:
Stage 2 – L CS bypass + TEVAR
45 y/o female with type B aortic dissection and aberrant R subclavian artery (BMI 42)
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Type B aortic dissection and aberrant R subclavian artery: Follow up 68 y/o with enlarging aneurysm with Type B aortic dissectionStage 1 RCCA to LCCA bypass; LCCA to L SC transpositionStage 2: TEVAR Zone 1
37 y/o s/p Aortic Coarctation repair (age 14) and Apico – DTA bypass (age 27; thrombosed for 14 mo)
with severe HTN and claudicationEndovascular Elephant Trunk
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Staged Approach …. Expanded!
Staging Decreases
Risk
Combined Endovascular and Surgical Approach• Patient selection
Surgical vs. hybrid vs. endovascular repair• Individualized plan
Reduce risk of debranching componentMust accomplish adequate seal zones
• Staging reduces riskSingle stage: Urgent indications
Antegrade deployment zone 0 (arch)• Interval rupture is a risk
Second stage during same admision
Staged retroperitoneal debranching for hybrid repair of type III TAA
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Infrarenal Aortic Replacement as Part of Debranching
Graft size to match available endograftMay require distal tapering
Pledgeted proximal anastomosis
Aortic Wrap
Circumference = �x diameter (endograft)
Combined Endovascular and Surgical Approach to Thoraco-abdominal Pathology: Conduit placement (1rst stage) and thrombectomy (2nd stage)
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North American Complex Abdominal Aortic Debranching(NACAAD) Registry
• High risk patients with complex TAA• Spinal cord ischemia : 159 patients
Transient 10 / 159; 6.2%Permanent 12 / 159; 7.5%Mortality 16%Risk Type II, coverage, rupture,
renal insufficiency• Ischemic colitis : 208 patients – 6%
Mortality w/o IC – 14%Mortality w IC – 46%Risk Single stage, age,
comorbidity score
1998 - 2013 – 51 high risk patients
40 TAA – 8 II, 23 III, 9 IV
5.8 % mortality: 2 interval aneurysm ruptures
1 arch debranching / retrograde dissection
Paraplegia – 2/40 at risk (5 %); II,III 1/ (3.2%)
2 year cumulative survival – 78%
2009
CESA (Hybrid) RepairAortic Arch Pathology
Arch debranching and Endovascular repair13 reported series > 10 cases reported as of 2011
• Mortality 0 - 20% Avg 7.9% UCLA 5.2%• Stroke 0 – 19% Avg 5% UCLA No strokes• All patients “high risk”• Some series include cases with CPBP/ deep
hypothermia• CESA for Arch << CESA for TAA
Durable?
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Durable
Combined
Endovascular
and
Surgical
Approach
(CESA or
Hybrid Approach)
11 yrfollow up
Durable?
Combined
Endovascular
and
Surgical
Approach
(CESA or
Hybrid Approach)
13 yrfollow up
Durable
Combined
Endovascular
and
Surgical
Approach
(CESA or
Hybrid Approach)
13 yrfollow up
“Hybrid” vs. Total Endovascular RepairHybrid� More invasive� Surgical skill > endovascular skill� Less affected by tortuosity and
or occlusive disease� Great for surgical training� Available today
Total endovascular repair� Less invasive� Endovascular skill > surgical skill� Significantly affected by tortuosity, occlusive disease� Evolving technology; risk EV Cx long term� Not available for now; to all
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The hybrid approach has a role todayand in the future
Vascular surgeons are best (only?)to offer all alternatives