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

4/4/2014

2

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)

4/4/2014

3

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

4/4/2014

4

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

4/4/2014

5

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)

4/4/2014

6

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?

4/4/2014

7

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

4/4/2014

8

The hybrid approach has a role todayand in the future

Vascular surgeons are best (only?)to offer all alternatives