Hybrid thoracic endovascular aortic repair: Pushing the envelope

Objective: Thoracic endovascular aortic repair (TEVAR) can be limited by inadequate proximal and distal landing zones. Debranching or hybrid TEVAR has emerged as an important modality to expand landing zones and facilitate TEVAR. We report a single-center experience with hybrid TEVAR. Methods: We retrospectively reviewed all patients with thoracic aortic disease who received a TEVAR between February 2005 and October 2008. Results: Forty-two patients underwent a hybrid procedure (mean age 68 ± 13 years; 55% men). All patients were denied open surgery due to preoperative comorbidities or low physiologic reserve; 62% had a history of coronary artery disease, 67% had chronic obstructive pulmonary disease, 61% had undergone prior aortic surgery, and 90% had an American Society of Anesthesiology score of 4 and above. The average Society for Vascular Surgery comorbidity score was 12 ± 2 with a range of 9 to 14. Fifty-five percent of cases were symptomatic on presentation and 83% were done emergently. Seventy-six percent underwent debranching of the aortic arch, 17% of the visceral vessels, and 7% required both. Primary technical success was achieved in all cases and of these, 43% were staged. The 30-day mortality was 5%. Myocardial infarction developed in 5%, respiratory failure in 31%, cerebrovascular accident (stroke or transient ischemic attack) in 19%, and spinal cord ischemia with ensuant paraplegia occurred in 5% of patients. Fifty-eight percent of patients were discharged home, 11% required rehabilitation, and 29% were transferred to a skilled nursing facility. There was a significant association between visceral vessel debranching and both spinal cord ischemia (P = .004) and gastrointestinal complications (P = .005). On the other hand, there was no difference between staged and non-staged hybrid procedures. Conclusions: Hybrid procedures can successfully extend the range of patients suitable for a subsequent TEVAR. These procedures are associated with higher complication rates than isolated infrarenal or thoracic endovascular repair, but given the medical and anatomical complexity of these patients, the current results are quite encouraging.