Combined endovascular and surgical approach (CESA) to thoracoabdominal aortic pathology: A 10-year experience

Objective: The first combined endovascular and surgical approach for thoracoabdominal aortic aneurysm was performed at our institution in 1998. We report a 10-year experience with a hybrid approach to thoracoabdominal aortic pathology. Methods: Records of all patients undergoing a combined endovascular and surgical approach to thoracoabdominal aortic pathology were reviewed. Presenting symptoms, perioperative morbidity and mortality, sequence (single versus two stages), and late results were analyzed. Results. From 1998 to 2008, 20 patients were treated with hybrid repairs for thoracoabdominal aneurysm (TAA) (15; four with dissection), aortic arch aneurysm (two), symptomatic supravisceral abdominal aortic aneurysm (one), contained perirenal pseudoaneurysm rupture (one), and floating aortic arch thrombus with cerebral and renal emboli in one patient. Ten patients had prior aortic grafting, one patient had a functional renal transplant, and all patients were considered high risk based on preoperative comorbidities. Aneurysm related pain (11) or aneurysm growth (eight), mesenteric ischemic symptoms (four), and peripheral embolization (one) were indications for intervention. Spinal catheter drainage was used routinely. The procedure was completed in a single stage (13), or two stages using a subcutaneous conduit constructed at die first stage (six). One patient refused the second stage and expired from aneurysm rupture five months later. There were nine major complications in six patients (32% morbidity); all recovered except one patient with complete aortic coverage from left subclavian to bifurcation in the single stage group who developed paraplegia (one of 15 patients at risk; 6.6%). There was no perioperative mortality (0-30 days or discharge). Two patients had successful re-intervention for a type I (included as a major complication) and II endoleak respectively. Two type II endoleaks without aneurysm growth continue under observation. There has been no graft thrombosis, aneurysm growth, or rupture during a mean follow-up of 16.6 months (range, 1-119 months) in 19 patients with a completed procedure (none lost to follow up). Cumulative survival at two years is 76%. Conclusions: A combined endovascular and surgical approach to thoracoabdominal aortic pathology can be performed in high-risk patients with acceptable morbidity and mortality. A two-stage approach is preferable when extensive coverage of the aorta is necessary and a subcutaneous conduit simplifies the second stage. Follow-up of 10 years in our initial patient suggests that this approach can be durable. Additional experience and longer follow-up is needed before expanding current indications for this approach. (J Vase Surg 2009;49:1125-34.)