Thoracoabdominal aneurysm repair: Hybrid versus open repair

Objective: Hybrid repair of thoracoabdominal aortic aneurysms (TAAA) may reduce morbidity and mortality in high-risk candidates for open repair. This study reviews the outcomes of hybrid TAAA repair for Crawford extent I-III TAAA in high-risk patients in comparison to patients who underwent concurrent open TAAA repair. Methods. During the interval from June 2005 to December 2007, a total of 23 high-risk patients with TAAA (type 1: 9 [39%], 11: 5 [22%], and 111: 9 [39%]) underwent renal and/or mesenteric debranching (11 [48%] with four vessel debranching) with subsequent placement of a thoracic stent graft; 77 patients underwent open TAAA repair (type 1: 13 [17%], 11: 11 [14%], 111: 27 [35%], and IV: 26 [34%]) during the same interval. The primary high-risk criteria for hybrid TAAA included advanced age/poor functional status (n = 14), major pulmonary dysfunction (n = 8), and technical consideration (prior thoracic aortic aneurysm repair [n = 4] or prior thoracoabdominal aneurysm repair [n = 21 and obesity [n = 21) with 6 patients having overlapping high-risk criteria. Composite (30-day) mortality and/or permanent paraplegia (PP) were the major study endpoints. Results: The hybrid and open TAAA groups had (respectively) no statistical difference in mean age (76.6 vs 72.7 years), aneurysm size (6.51 vs 6.52 cm), and non-elective operation (30.4% vs 26.0%). The hybrid group had a higher mean Society for Vascular Surgery (SVS) risk score (9.1 vs 6.0; P <= .001), incidence of oxygen-dependent chronic obstructive pulmonary disease (COPD) (34.8% vs 2.6%; P <= .001), and prior thoracic (n = 4) or thoracoabdominal (n = 2) repair (26.1% vs 1.3%; P <= .001). Composite mortality and/or PP was doubled in the hybrid group (21.7% vs 11.7%; P = .33). The rate of any type of reoperation was higher in hybrid TAAA repair (39.1% vs 20.8%; P = .03). One year actuarial survival for both groups was comparable (hybrid, 68 +/- 12%; open, 73 +/- 6%). A total of 5/23 (22%) hybrid TAAA patients developed an endoleak (type I: 3/23 and type II : 2/23) with 3 requiring endovascular re-intervention. A total of 7/70 (10%) visceral/renal bypass grafts were noted to be occluded during follow-up (I superior inesenteric artery, 1 celiac, and 5 renal). Examination of patients with an SVS risk score :58 (mean SVS risk score in hybrid 6.2 [n = 10] vs 5.5 [n = 68] in open; P = .27) revealed the hybrid group had a higher incidence of composite mortality and/or PP (40% vs 10.3%; P = .03). Conclusion: Hybrid TAAA repair in high-risk patients has significant morbidity and mortality suggesting a non-interventional approach may be appropriate in many such patients. The morbidity and mortality of the hybrid TAAA repair was substantial even in lower risk patients (SVS risk score <= 8), albeit patient numbers were small. Prospective study in comparable patient risk cohorts is required to define the role of hybrid TAAA repair. (J Vasc Surg 2009;50: 15-22.)