Hybrid repair of complex thoracoabdominal aortic aneurysms using applied endovascular strategies combined with visceral and renal revascularization

Objective: We sought to report our experience with combined retrograde visceral revascularization and endovascular exclusion (hybrid procedure) of thoracoabdominal aortic aneurysms. Methods: From February 2005 to October 2007, the prospectively collected data of 18 consecutive patients undergoing hybrid repair were analyzed. Median age was 73 years; Crawford-Safi extent included 2 type I, 8 type II, 7 type III, and 1 type V thoracoabdominal aortic aneurysms; 13 were atherosclerotic and 5 were postdissecting aneurysms. Previous open or endovascular aortic surgery had been performed in 11 (61.1%) patients. Society for Vascular Surgery/North American Chapter of the International Society for Cardiovascular Surgery preoperative risk stratification identified mild-to-severe hypertension and pulmonary and cardiac status in 88.9%, 67.7%, and 88.9% of the patients, respectively. Results: Fifty-four visceral vessels were bypassed in 18 patients. As an adequate inflow site, the common iliac artery was identified in 15 (83.3%) patients, the infrarenal native aorta was identified in 1 (5.6%) patient, and a previous tube graft was identified in 2 (11.1%) patients. Median operating time was 360 minutes (range, 210-600 minutes), and median blood loss was 3200 mL (range, 1000-18,000 mL). Aneurysm exclusion was achieved in 17 patients. Thirty-day mortality was 16.7% (n = 3/18). Complications included paraplegia (n = 1) and acute myocardial infarction (n = 2). Median follow-up was 23 months (range, 8-42 months), with visceral graft patency at follow-up or death of 98.1% (n = 53/54). One early and 1 late type Ia endoleak (11.8%, n = 2/17), no type III endoleaks, and 5 type II endoleaks were detected, none necessitating adjuvant procedures. Conclusion: The visceral hybrid repair is a feasible and relatively safe procedure for extensive thoracoabdominal aortic aneurysms. Even considering the significantly high mortality and morbidity rates, it might represent a viable alternative in a cohort of patients historically deemed at high risk for traditional surgical intervention. (J Thorac Cardiovasc Surg 2009;138:1331-8)