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Many patients with poor cardiopulmonary status do not tolerate open surgery and endovascular repair, which is less invasive and potentially safer, is sometimes chosen for treatment. However, a significant number of high-risk patients are not suitable for endovascular approach alone.

In a recent study, Wei Zhou, MD, a vascular surgeon at Baylor College of Medicine in Houston, suggests that a “hybrid” approach may work for a large number of patients who are not fit for either open surgery repair or endovascular treatment alone.

“Our group utilized a combined open surgical and endovascular approach for high-risk patients with complex thoracic aortic aneurysms who are unsuitable for endovascular treatment alone,” said Dr. Zhou. The findings were published in the October issue of the Journal of Vascular Surgery.

Some patients have unsuitable anatomies for endovascular surgery alone, particularly inadequate landing zones, said Dr. Zhou. “When these patients have endovascular repair of an aneurysm, stentgrafts may cover carotid arteries when placed in the upper thoracic aorta or visceral vessels when placed in the lower thoracic aorta,” she said, “Covering any of these arteries can result in catastrophic events that are potentially life-threatening.”

Thirty-one high-risk patients underwent a combined approach for thoracic aortic aneurysms excluding patients with history of aortic dissection or connective tissue diseases.  Of the 31 patients, 10 had severe chronic obstructive pulmonary disease that prohibited open thoracotomy and 29 had significant coronary artery diseases prohibiting aortic cross clamping.  Eleven patients had previous aortic aneurysm repairs that significantly increased surgical challenges.  

Due to anatomical limitations, adjunctive surgical maneuvers were used including aortic arch reconstruction (three patients), supra-aortic trunk debranching (13 patients), and visceral vessel bypasses (15 patients). Additionally, carotid artery access was performed in one patient and iliac artery conduit creations were used in 12 patients.

According to Dr. Zhou, all of the cases were technically successful. There was one perioperative death due to postoperative bleeding; two patients had immediate Type II endoleak which were resolved within a month; two had transient renal failure; and a retroperitoneal hematoma was successfully managed conservatively in one patient. During a mean follow-up of 16 months, two patients died of unrelated causes while all remaining patients were asymptomatic without aneurysm enlargement.  

“Until branched aortic endografts become available, surgical debranching technique combined with endovascular aortic stent grafting provides a valuable alternative for the management of complex thoracic aneurysms,” Dr. Zhou added, “it is an attractive solution for patients with poor cardiopulmonary reserves and this combined approach expands the aortic territory that can be grafted. Some of these adjunctive procedures remain major operations, but they avoid the requirements of aortic cross clamping and the potential needs for hypothermic circulatory arrest.”