Mid-term results of hybrid aortic repair using a custom quadfurcated graft

Ali Khoynezhad MD, PhD, FACS, FACCAssociate Professor of Cardiovascular Surgery

Director of Aortic SurgeryDivision of Cardiothoracic Surgery

Cedars-Sinai Medical CenterLos Angeles, CA

Background Patients with anatomic or physiologic constrains are poor endovascular or open candidates.

Hybrid repair with early promising results in this high-risk cohort

Aim of this study: feasibility and midterm follow-up of hybrid aortic repairs using a custom graft

Same graft can be used for hybrid arch or TAAA repair.

Why Hybrid?

Stroke risk up to 12%,

Mortality up to 20%

Proximal vs distal arch outcomes

Respiratory failure

Recurrent nerve injury

no aortic cross-clamping

Avoid second stage elephant trunk

& the interval mortality

342 TEVARs between 2005-2011

195 patients requiring combined open/endovascular approach

52 patients with custom graft

Indications: aneurysm in 31, chronic dissection in 15, acute type A dissection in 6

18 (35%) had hybrid TAAA

34 (65%) zone 0 hybrid arch repair

Patient Cohort

Comorbidities

Age 68 ±11 years (range 59-83)

15 (29%) patients had prior aortic operation or procedure.

12 (23%) urgent/emergent

22 (43%) with severe COPD

10 (19%) prior stroke/TIA

14 (27%) with prior MI

19 (37%) with moderate eGFR reduction (stage III CKD)

In 40 (77%) patients endovascular exclusion was performed simultaneously.

Two (4%) patients developed permanent stroke perioperatively.

No patients with spinal cord injury.

No type I or III endoleak.

No perioperative MI

6 (12%) with acute kidney injury, no new-onset hemodialysis.

11 (21%) atrial fibrillation

Results

Early mortality was 6% (n=3).

1-year and 4-year mortality were 90% & 79%

Results (cont.)

51(98%) with complete follow-up.

Office visit and imaging follow-up at 1, 6, 12 months & yearly thereafter.

At a mean follow-up of 34 ± 11 months, there were six additional late deaths (none related to aorta).

All debranching bypass grafts have remained patent.

One endovascular re-intervention at 8 months.

Follow-up

Extra-anatomic bypass off left common iliac artery

Celiac artery

Superiormesenteric

artery

Bypass graft to right renal artery after a small

Kocher maneuver;this branch is tunneled from left to right gutter in the retroperitoneal

space.

Komplettetransposition

viszeraler Gefaesse

Conclusions Hybrid aortic repair using quadfurcated graft appears to be feasible, safe and effective at mid-term follow-up.

Hybrid aortic repair represents a feasible alternative in high-risk patients.

Long-term surveillance requiring contrast administration and radiation exposure remains an unresolved issue.

Long-term results need to be established.