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Hybrid Repair of Thoracoabdominal Aortic Aneurysm Repair with Visceral Vessel Debranching and Aortic Endograft Exclusion: Effect of Staged versus Simultaneous Treatment Approach on Clinical Outcomes

Background: Visceral vessel debranching and endovascular aneurysm exclusion represents a hybrid treatment approach in patients with pararenal aortic aneurysm or thoracoabdominal aortic aneurysm (TAAA). However, the effect of timing with regard to the visceral debranching procedure and endovascular aneurysm exclusion in this treatment strategy remains unclear. In this study, we analyzed the effect of staged versus simultaneous hybrid treatment in patients with complex aortic aneurysms.
Methods: Clinical records of 38 patients who underwent hybrid repair of pararenal aortic aneurysm or TAAA (Crawford extent III or IV) during a recent 27 months were reviewed. Simultaneous visceral debranching and endograft exclusion were performed in 16 patients (group 1), while staged hybrid repair was performed in 22 patients (group 2). Treatment outcomes were compared.
Results: Both groups shared similar demographic data and aneurysm size. In group 1 and 2, history of prior abdominal operation was noted 36% and 45%, respectively (NS). In group 2, the mean duration of staged repair was 9.5 days (range 3-32 days). Two patients in group 2 died before undergoing staged endograft exclusion procedure, presumably due to aneurysm rupture. Thirty-day mortality rate in group 1 and 2 was 13% and 18%, respectively (NS). Postoperative renal insufficiency (serum Creatinine > 2.0 mg/dL) was significantly higher in group 1 as compared to group 2 (87% vs. 45%, respectively, p<0.02). Similarly, the need for hemodialysis was greater in group 1 then in group (25% vs. 9%, respectively, p<0.04). Mean cumulative ICU length of stay in group 1 and 2 was 5.5 days and 8.5 days, respectively (p<0.03). Mean cumulative hospital length of stay in group 1 and 2 was 9.8 days and 12.2 days, respectively (p<0.05). During a mean follow-up of 19 months, visceral graft occlusion was noted in 18% of patients in group 1 and 22% of patients in group 2 (NS). Abdominal re-exploration or graft thrombectomy was necessary in three patients in group 2 (13%) and four patients in group 2 (18%). Mid-term follow-up showed four patients in group 1 (25%) and six patients in group 2 (27%) died of non-aneurysm related causes.
Conclusions: Our study showed a high incidence of renal insufficiency in patients undergoing a combined hybrid repair than staged hybrid approach. In contrast, patients undergoing staged hybrid repair had a greater cumulative ICU and hospital length of stay. Possibility of aneurysm rupture may exist in staged treatment approach if the duration of staged repair is prolonged. The hybrid treatment strategy should be performed with caution. Further comparison of hybrid repair and convention TAAA repair is needed to validate the efficacy of this treatment strategy.