Hybrid thoracoabdominal aortic aneurysm repair: concomitant visceral revascularization and endovascular aneurysm exclusion

Abstract

Thoracoabdominal aortic aneurysms (TAAA) remain a formidable surgical challenge, with conventional open repair associated with significant rates of mortality and morbidity. Furthermore, many of these patients are elderly with significant comorbidities and may not be candidates for repair. Consequently, the availability of a "hybrid" option, including open visceral debranching with concomitant endovascular aneurysm exclusion, may have advantages in these high-risk patients, including the potential to offer therapy to those ineligible for conventional repair. Our technique for hybrid TAAA repair is performed by means of midline laparotomy. A commercially manufactured custom multibranched Dacron graft is used to sequentially bypass, in extranatomic manner, the left renal artery, superior mesenteric artery, celiac axis, and right renal artery. Inflow is through a single proximal anastomosis to the iliac system, infrarenal aorta, or an existing infrarenal aortic graft. In all cases, endovascular exclusion of the aneurysm has been performed at the same operation. The procedure is applicable to all types of TAAA (Extent I-V), although a bifurcated abdominal aortic endograft may be required if inadequate distal landing zone for a tube endograft exists above the aortic bifurcation. Results to date suggest this technique of "hybrid" TAAA repair to be a safe alternative to conventional repair for TAAA in older patients with significant comorbidity, with results in our institution similar to those previously published for younger patients undergoing conventional repair in high-volume centers.