Ten-year experience of the thoraco-abdominal aortic aneurysm treatment using a hybrid thoracic endovascular aortic repair

Ten-year experience of the thoraco-abdominal aortic aneurysm treatment using a hybrid thoracic... Abstract OBJECTIVES The treatment of thoraco-abdominal aortic aneurysm continues to have a high mortality and paraplegia rate. In superaging societies, the methods of performing less invasive operations remain a major issue. We reviewed our 10-year experience in the treatment of thoraco-abdominal aortic aneurysm using a hybrid procedure of combined visceral reconstruction and thoracic endovascular aortic repair. METHODS Sixty patients underwent a hybrid repair for the treatment of the thoraco-abdominal aortic aneurysm between 2007 and 2016. The mean age was 72.7 years. A true aneurysm was found in 43 (72%) patients and a chronic dissection in 17 (28%) patients. The standard operative procedure involved replacing the abdominal aorta with an artificial graft, and the visceral arteries were reconstructed using a quadrifurcated graft. Renovisceral debranching and stent grafting were performed as a 2-stage procedure. RESULTS The hospital mortality rate was 5%. Two (3%) patients died due to an aneurysmal rupture in the hospital just after renovisceral debranching. The other 2 patients died due to an aneurysmal rupture in the long-term period after preventive renovisceral debranching. Two (3%) patients experienced spinal cord ischaemia after the stenting procedure. Four (7%) patients required additional treatment during the follow-up period. The overall survival was 75.9% at 2 years, 65.2% at 5 years and 43.5% at 8 years. The rates of freedom from aorta-related events were 92.9% at 2 years, 80.5% at 5 years and 72.5% at 8 years. CONCLUSIONS The hybrid repair is considered to be a good option for elderly and high-risk patients. Further long-term follow-up is necessary to extend the indication in younger patients. Thoraco-abdominal aortic aneurysm, Hybrid thoracic endovascular aortic repair, Renovisceral debranching INTRODUCTION The treatment of thoraco-abdominal aortic aneurysms (TAAAs) is still challenging, as the mortality of conventional open surgery is not very promising when compared with other aortic operations, and the incidence of spinal cord ischaemia, which greatly affects the postoperative quality of life, is relatively high. In Japan, which is becoming a superaging society, the method of performing minimally invasive operations for elderly and high-risk patients remains a major issue. In this era, endovascular aortic repair and thoracic endovascular aortic repair (TEVAR) have developed as minimally invasive surgeries for aortic pathologies. Hybrid repair (renovisceral debranching plus endovascular exclusion) that takes advantage of endovascular treatment has emerged as an alternative operation for the treatment of TAAAs in the endovascular era. Regarding the results, a few reports targeting more than 50 patients have described the mortality rate as 0–24.1% and the incidence of spinal cord ischaemia as 0–8.6% [1–7]. Some of these reports have described medium-term to long-term outcomes of more than 5 years, so there is room for discussion on whether this hybrid repair of TAAAs can be applied to all patients, including young patients. We reviewed our total experience. We classified the patients into 2 groups comprising those <70 and ≥70 years of age and evaluated the early and long-term results obtained from this hybrid procedure. PATIENTS AND METHODS Data source This is a single-centre series of 60 consecutive patients who underwent renovisceral debranching TEVAR for TAAAs between 2007 and 2016. One case in 2007, 1 case in 2008, 3 cases in 2009, 4 cases in 2010, 6 cases in 2011, 10 cases in 2012, 6 cases in 2013, 12 cases in 2014, 8 cases in 2015 and 9 cases in 2016 underwent surgery consisting of hybrid TEVAR. Sixteen patients underwent conventional open TAAAs repair during this period. Regarding patient selection, all patients older than 70 years who were not emergency cases were targeted for hybrid TEVAR between 2007 and 2011. We extended the indication to patients aged 60 years and younger in 2012. This retrospective study was approved by the Institutional Review Board of the Oita University Hospital, and the need for individual patient consent was waived. Treatment strategy of thoraco-abdominal aortic aneurysms We perform the renovisceral debranching operation and TEVAR in 2 stages for TAAAs including chronic dissection with aneurysmal size exceeding 55 mm. When the aneurysmal size is >60 mm, the next TEVAR is performed within a few days after the renovisceral debranching procedure. When the aneurysmal size is <60 mm, the next TEVAR is performed after the recovery of activity of daily living. In addition, when graft replacement for abdominal aortic aneurysm is performed, if there are any aneurysms exceeding 50 mm in size in the thoraco-abdominal region then a renovisceral debranching operation is performed simultaneously, so that TEVAR can be performed in future. We specify this as a preventive renovisceral debranching surgery. Operative procedure A renovisceral debranching operation is performed using median laparotomy. Initially, the visceral branches [celiac trunk, superior mesenteric artery (SMA) and bilateral renal artery] are secured. Normally, the abdominal aorta is replaced with a bifurcated graft. When the abdominal aorta and iliac artery are well characterized and there are no problems with the stent graft’s access or landing, there is no need to intentionally replace the abdominal aorta with an artificial graft. The quadrifurcated graft, known as the ‘InterGard Quattro’ (Getinge Group Japan, Inc., Tokyo, Japan), is anastomosed to the left leg of the bifurcated graft, and the visceral arteries are reconstructed using the quadrifurcated graft. If the patients have previously undergone abdominal aortic repair, re-replacement of the abdominal graft is unnecessary, and a quadrifurcated graft for renovisceral debranch should be anastomosed to the left leg of the existing graft. In our facility, the quadrifurcated graft uses a size of 14 × 7 × 6 mm. The proximal site of the renal artery is cut-off using Hem-o-lok® (Teleflex, Inc., Morrisville, NC, USA) and transected. Renal protection using an injection of 500 ml of chilled bicarbonate Ringer’s solution mixed with D-mannitol, heparin and sodium bicarbonate is achieved for patients with an impaired renal function. The bilateral renal artery is reconstructed with an end-to-end anastomosis of a 6-mm graft. The proximal site of the celiac trunk and SMA are also cut-off using Hem-o-lok® and reconstructed with an end-to-side anastomosis of a 7-mm graft. Finally, we make a bypass between the abdominal graft and the right femoral artery with a 10-mm graft if iliac artery is poorly characterized. This will be the access route for the next TEVAR. A picture of the operative field after abdominal debranching is shown in Fig. 1A. Figure 1: View largeDownload slide (A) A picture of operative field after abdominal debranching. (B) Postoperative 3D computed tomography of renovisceral debranching and thoracic endovascular aortic repair. Figure 1: View largeDownload slide (A) A picture of operative field after abdominal debranching. (B) Postoperative 3D computed tomography of renovisceral debranching and thoracic endovascular aortic repair. Renovisceral debranching and TEVAR are performed as a 2-stage procedure. Normally, TEVAR is performed with local anaesthesia under sedation with intravenous anaesthesia. In such cases, cerebrospinal fluid drainage for spinal cord protection is not absolutely necessary, as blood pressure can be easily kept in a stable state. Vascular access for TEVAR is femoral artery or graft anastomosed to the femoral artery. In TEVAR, various stent grafts are selectively used depending on their features. Completed 3D computed tomography (CT) of renovisceral debranching and TEVAR is shown in Fig. 1B. Postoperative follow-up In all cases, contrast CT was performed for the planning of treatment before surgery. Postoperative patients were evaluated by CT at 1, 6 and 12 months and every year thereafter. Statistical analysis All data are analysed retrospectively. Continuous variables are expressed as the mean ± standard deviation. Categorical variables are presented as the number and percentage. The survival and freedom from aortic events are determined by the Kaplan–Meier methods of estimation. All analyses are performed using the Excel statistical software package (Ekuseru-Toukei 2015; Social Survey Research Information Co., Ltd., Tokyo, Japan). RESULTS Patient demographics Patient demography and comorbidities are summarized in Table 1. Forty-two (70%) patients were men. The mean patient age was 72.7 ± 9.9 years (range 47–89 years). Patients older than 70 years accounted for 68%. There were 49 (82%) patients with hypertension, 25 (42%) with hyperlipidaemia and 9 (15%) with diabetes mellitus. Fifteen (25%) patients had a history of treatment of coronary artery disease, and 7 (12%) patients had cerebrovascular disease. Seventeen (28%) patients had chronic obstructive pulmonary disease; however, there were no patients with domiciliary oxygen therapy. Forty-two (70%) patients showed chronic kidney disease of G3 (30 ≤ estimated glomerular filtration rate < 60) or higher. Fourteen (23%) patients were G3b (30 ≤ estimated glomerular filtration rate < 45), and 9 (15%) were G4 (15 ≤ estimated glomerular filtration rate < 30); however, there were no patients with haemodialysis. Especially, severe renal dysfunction was commonly observed in patients ≥70 years of age. There were no patients with any type of connective tissue disease. Three (13%) patients had a history of cardiac surgery, and 35 (58%) had a history of aortic surgery. The ascending aortic replacement was performed in 1 case (2%), aortic arch replacement in 20 cases (33%), descending aortic replacement in 9 cases (15%) and abdominal aortic replacement in 13 cases (22%). Table 1: Patient demography and comorbidity Variables Total (%) <70 years of age (%) ≥70 years of age (%) Patients 60 (100) 19 (32) 41 (68) Gender  Male 42 (70) 16 (84) 26 (63)  Female 18 (30) 3 (16) 15 (37) Mean age (years) 72.7 60.4 78.4  70s 21 (35) 21 (51)  80s 20 (33) 20 (49) Hypertension 49 (82) 17 (89) 32 (78) Hyperlipidaemia 25 (42) 7 (37) 18 (44) Diabetes mellitus 9 (15) 4 (21) 5 (12) Coronary artery disease 15 (25) 4 (21) 11 (27) Cerebrovascular disease 7 (12) 4 (21) 3 (7) COPD 17 (28) 4 (21) 12 (32) CKD  G3a (45 ≤ eGFR < 60) 19 (32) 4 (21) 15 (37)  G3b (30 ≤ eGFR < 45) 14 (23) 3 (16) 11 (27)  G4 (15 ≤ eGFR < 30) 9 (15) 0 9 (22)  Dialysis 0 0 0 Prior cardiac surgery 8 (13) 4 (21) 4 (12) Prior aortic surgery 35 (58) 13 (68) 22 (54)  Ascending 1 (2) 1 (5) 0  Arch 20 (33) 10 (53) 10 (24)  Descending 9 (15) 3 (16) 6 (15)  Thoraco-abdominal 0 0 0  Abdominal 13 (22) 3 (16) 10 (24) Variables Total (%) <70 years of age (%) ≥70 years of age (%) Patients 60 (100) 19 (32) 41 (68) Gender  Male 42 (70) 16 (84) 26 (63)  Female 18 (30) 3 (16) 15 (37) Mean age (years) 72.7 60.4 78.4  70s 21 (35) 21 (51)  80s 20 (33) 20 (49) Hypertension 49 (82) 17 (89) 32 (78) Hyperlipidaemia 25 (42) 7 (37) 18 (44) Diabetes mellitus 9 (15) 4 (21) 5 (12) Coronary artery disease 15 (25) 4 (21) 11 (27) Cerebrovascular disease 7 (12) 4 (21) 3 (7) COPD 17 (28) 4 (21) 12 (32) CKD  G3a (45 ≤ eGFR < 60) 19 (32) 4 (21) 15 (37)  G3b (30 ≤ eGFR < 45) 14 (23) 3 (16) 11 (27)  G4 (15 ≤ eGFR < 30) 9 (15) 0 9 (22)  Dialysis 0 0 0 Prior cardiac surgery 8 (13) 4 (21) 4 (12) Prior aortic surgery 35 (58) 13 (68) 22 (54)  Ascending 1 (2) 1 (5) 0  Arch 20 (33) 10 (53) 10 (24)  Descending 9 (15) 3 (16) 6 (15)  Thoraco-abdominal 0 0 0  Abdominal 13 (22) 3 (16) 10 (24) COPD: chronic obstructive pulmonary disease; CKD: chronic kidney disease; eGFR: estimated glomerular filtration rate. Table 1: Patient demography and comorbidity Variables Total (%) <70 years of age (%) ≥70 years of age (%) Patients 60 (100) 19 (32) 41 (68) Gender  Male 42 (70) 16 (84) 26 (63)  Female 18 (30) 3 (16) 15 (37) Mean age (years) 72.7 60.4 78.4  70s 21 (35) 21 (51)  80s 20 (33) 20 (49) Hypertension 49 (82) 17 (89) 32 (78) Hyperlipidaemia 25 (42) 7 (37) 18 (44) Diabetes mellitus 9 (15) 4 (21) 5 (12) Coronary artery disease 15 (25) 4 (21) 11 (27) Cerebrovascular disease 7 (12) 4 (21) 3 (7) COPD 17 (28) 4 (21) 12 (32) CKD  G3a (45 ≤ eGFR < 60) 19 (32) 4 (21) 15 (37)  G3b (30 ≤ eGFR < 45) 14 (23) 3 (16) 11 (27)  G4 (15 ≤ eGFR < 30) 9 (15) 0 9 (22)  Dialysis 0 0 0 Prior cardiac surgery 8 (13) 4 (21) 4 (12) Prior aortic surgery 35 (58) 13 (68) 22 (54)  Ascending 1 (2) 1 (5) 0  Arch 20 (33) 10 (53) 10 (24)  Descending 9 (15) 3 (16) 6 (15)  Thoraco-abdominal 0 0 0  Abdominal 13 (22) 3 (16) 10 (24) Variables Total (%) <70 years of age (%) ≥70 years of age (%) Patients 60 (100) 19 (32) 41 (68) Gender  Male 42 (70) 16 (84) 26 (63)  Female 18 (30) 3 (16) 15 (37) Mean age (years) 72.7 60.4 78.4  70s 21 (35) 21 (51)  80s 20 (33) 20 (49) Hypertension 49 (82) 17 (89) 32 (78) Hyperlipidaemia 25 (42) 7 (37) 18 (44) Diabetes mellitus 9 (15) 4 (21) 5 (12) Coronary artery disease 15 (25) 4 (21) 11 (27) Cerebrovascular disease 7 (12) 4 (21) 3 (7) COPD 17 (28) 4 (21) 12 (32) CKD  G3a (45 ≤ eGFR < 60) 19 (32) 4 (21) 15 (37)  G3b (30 ≤ eGFR < 45) 14 (23) 3 (16) 11 (27)  G4 (15 ≤ eGFR < 30) 9 (15) 0 9 (22)  Dialysis 0 0 0 Prior cardiac surgery 8 (13) 4 (21) 4 (12) Prior aortic surgery 35 (58) 13 (68) 22 (54)  Ascending 1 (2) 1 (5) 0  Arch 20 (33) 10 (53) 10 (24)  Descending 9 (15) 3 (16) 6 (15)  Thoraco-abdominal 0 0 0  Abdominal 13 (22) 3 (16) 10 (24) COPD: chronic obstructive pulmonary disease; CKD: chronic kidney disease; eGFR: estimated glomerular filtration rate. Preoperative aortic characteristics The aortic characteristics are summarized in Table 2. Aortic pathologies included 43 (72%) degenerative aneurysms and 17 (28%) chronic aortic dissection. Chronic dissection was frequently observed in patients younger than 70 years, whereas the occurrence of a true aneurysm frequently identified in patients ≥70 years of age. The mean aneurysmal size was 58.7 ± 7.1 mm (range 49–86 mm). Aneurysms were classified according to the modified Crawford classification [8]. Type V was the most frequent and found in 24 cases. Among them, 11 cases were complicated by an abdominal aortic aneurysm. In addition, Type I was found in 12 cases (20%), Type II in 8 cases (13%), Type III in 10 cases (17%) and Type IV in 6 cases (10%). There were 5 (8%) emergency and urgent operations. In 1 emergency case of an aneurysmal rupture and 2 urgent cases of an impending aneurysmal rupture, renovisceral debranching and TEVAR were performed simultaneously. In 2 urgent cases of an impending aneurysmal rupture, renovisceral debranching and TEVAR were performed separately. Table 2: Aortic characteristics Variables Total (%) <70 years of age (%) ≥70 years of age (%) Mean aneurysmal size (mm) 58.7 58.2 59.0 Aortic pathologies  Degenerative aortic disease 43 (72) 6 (32) 37 (90)  Chronic aortic dissection 17 (28) 13 (68) 4 (10) Crawford classification (modified)  Type I 12 (20) 2 (11) 10 (24)  Type II 8 (13) 8 (42) 0  Type III 10 (17) 6 (31) 4 (10)  Type IV 6 (10) 1 (5) 5 (12)  Type V 24 (40) 2 (11) 22 (54) Variables Total (%) <70 years of age (%) ≥70 years of age (%) Mean aneurysmal size (mm) 58.7 58.2 59.0 Aortic pathologies  Degenerative aortic disease 43 (72) 6 (32) 37 (90)  Chronic aortic dissection 17 (28) 13 (68) 4 (10) Crawford classification (modified)  Type I 12 (20) 2 (11) 10 (24)  Type II 8 (13) 8 (42) 0  Type III 10 (17) 6 (31) 4 (10)  Type IV 6 (10) 1 (5) 5 (12)  Type V 24 (40) 2 (11) 22 (54) Table 2: Aortic characteristics Variables Total (%) <70 years of age (%) ≥70 years of age (%) Mean aneurysmal size (mm) 58.7 58.2 59.0 Aortic pathologies  Degenerative aortic disease 43 (72) 6 (32) 37 (90)  Chronic aortic dissection 17 (28) 13 (68) 4 (10) Crawford classification (modified)  Type I 12 (20) 2 (11) 10 (24)  Type II 8 (13) 8 (42) 0  Type III 10 (17) 6 (31) 4 (10)  Type IV 6 (10) 1 (5) 5 (12)  Type V 24 (40) 2 (11) 22 (54) Variables Total (%) <70 years of age (%) ≥70 years of age (%) Mean aneurysmal size (mm) 58.7 58.2 59.0 Aortic pathologies  Degenerative aortic disease 43 (72) 6 (32) 37 (90)  Chronic aortic dissection 17 (28) 13 (68) 4 (10) Crawford classification (modified)  Type I 12 (20) 2 (11) 10 (24)  Type II 8 (13) 8 (42) 0  Type III 10 (17) 6 (31) 4 (10)  Type IV 6 (10) 1 (5) 5 (12)  Type V 24 (40) 2 (11) 22 (54) Early results In 60 cases, the debranching procedure was performed. A preventive renovisceral debranching procedure was performed in 10 (17%) of them. Regarding the renovisceral debranching procedure, the average operation time was 537 ± 120 min (range 305–840 min). The average number of anastomosis sites was 8.6 ± 2.2 (range 5–14). The average amount of bleeding was 2033 ± 1218 ml (range 500–4900 ml). Most patients required blood transfusions. The average stay in the intensive care unit was 3.6 ± 2.8 days (range 0–16 days). Early outcomes are summarized in Table 3. One patient with a true aneurysm had paraplegia after the renovisceral debranching operation though the cause was unknown. The patient died due to an aneurysmal rupture during hyperbaric oxygen therapy for the paraplegia. In addition to this patient, 2 cases of an aneurysmal rupture occurred while waiting for TEVAR. One case was rescued with emergency TEVAR, but another case resulted in death. Four cases (7%) of anastomotic haemorrhaging were found, and embolization and open haemostasis were performed. One (2%) patient who had CKD G4 before surgery newly started maintenance dialysis after the renovisceral debranching operation. Although 5 (8%) patients needed transient dialysis with continuous haemodiafiltration in the intensive care unit, everyone got off transient dialysis. Gastrointestinal dysfunction, such as intestinal obstruction and diarrhoea, was found in 6 (10%) patients. There were no respiratory complications. The total amount of visceral bypass grafts was 223. Quadruple bypasses (celiac, SMA and bilateral renal) were performed in 48 cases (80%). Triple bypasses (celiac, SMA and lateral renal: 4 and SMA and bilateral renal: 3) were performed in 7 cases (12%). Double bypasses (celiac and SMA) were performed in 5 cases (8%). Three of 223 grafts showed early occlusion, for an early graft patency rate of 98.7%. Twenty-one (35%) patients were evaluated by contrast CT for more than 1 year. The average follow-up period was 29.6 ± 14.2 months (range 12–60 months), in which there was no bypass late occlusion. Table 3: Early outcomes Variables Total (%) <70 years of age (%) ≥70 years of age (%) Major complications after renovisceral debranching  Aneurysm rupture while waiting for TEVAR 3 (5) 1 (5) 2 (5)  Paraplegia 1 (2) 1 (5) 0  Bleeding of anastomosis site 4 (7) 1 (5) 3 (7)  Newly maintenance dialysis 1 (2) 0 1 (2)  Occlusion of reconstructed renovisceral branch 3 (5) 0 3 (7)   Celiac trunk 2 (4) 0 2 (5)   Right renal artery 1 (2) 0 1 (2)  Respiratory dysfunction 0 0 0 Major complications after TEVAR  Paraplegia 2 (4) 0 2 (5)  DIC (bleeding tendency) 8 (15) 4 (21) 4 (10) Hospital mortality 3 (5) 1 (5) 2 (5)  Aneurysm rupture while waiting for TEVAR 2 (3) 1 (5) 1 (2)  Acute myocardial infarction 1 (2) 0 1 (2) Variables Total (%) <70 years of age (%) ≥70 years of age (%) Major complications after renovisceral debranching  Aneurysm rupture while waiting for TEVAR 3 (5) 1 (5) 2 (5)  Paraplegia 1 (2) 1 (5) 0  Bleeding of anastomosis site 4 (7) 1 (5) 3 (7)  Newly maintenance dialysis 1 (2) 0 1 (2)  Occlusion of reconstructed renovisceral branch 3 (5) 0 3 (7)   Celiac trunk 2 (4) 0 2 (5)   Right renal artery 1 (2) 0 1 (2)  Respiratory dysfunction 0 0 0 Major complications after TEVAR  Paraplegia 2 (4) 0 2 (5)  DIC (bleeding tendency) 8 (15) 4 (21) 4 (10) Hospital mortality 3 (5) 1 (5) 2 (5)  Aneurysm rupture while waiting for TEVAR 2 (3) 1 (5) 1 (2)  Acute myocardial infarction 1 (2) 0 1 (2) DIC: disseminated intravascular coagulopathy; TEVAR: thoracic endovascular aortic repair. Table 3: Early outcomes Variables Total (%) <70 years of age (%) ≥70 years of age (%) Major complications after renovisceral debranching  Aneurysm rupture while waiting for TEVAR 3 (5) 1 (5) 2 (5)  Paraplegia 1 (2) 1 (5) 0  Bleeding of anastomosis site 4 (7) 1 (5) 3 (7)  Newly maintenance dialysis 1 (2) 0 1 (2)  Occlusion of reconstructed renovisceral branch 3 (5) 0 3 (7)   Celiac trunk 2 (4) 0 2 (5)   Right renal artery 1 (2) 0 1 (2)  Respiratory dysfunction 0 0 0 Major complications after TEVAR  Paraplegia 2 (4) 0 2 (5)  DIC (bleeding tendency) 8 (15) 4 (21) 4 (10) Hospital mortality 3 (5) 1 (5) 2 (5)  Aneurysm rupture while waiting for TEVAR 2 (3) 1 (5) 1 (2)  Acute myocardial infarction 1 (2) 0 1 (2) Variables Total (%) <70 years of age (%) ≥70 years of age (%) Major complications after renovisceral debranching  Aneurysm rupture while waiting for TEVAR 3 (5) 1 (5) 2 (5)  Paraplegia 1 (2) 1 (5) 0  Bleeding of anastomosis site 4 (7) 1 (5) 3 (7)  Newly maintenance dialysis 1 (2) 0 1 (2)  Occlusion of reconstructed renovisceral branch 3 (5) 0 3 (7)   Celiac trunk 2 (4) 0 2 (5)   Right renal artery 1 (2) 0 1 (2)  Respiratory dysfunction 0 0 0 Major complications after TEVAR  Paraplegia 2 (4) 0 2 (5)  DIC (bleeding tendency) 8 (15) 4 (21) 4 (10) Hospital mortality 3 (5) 1 (5) 2 (5)  Aneurysm rupture while waiting for TEVAR 2 (3) 1 (5) 1 (2)  Acute myocardial infarction 1 (2) 0 1 (2) DIC: disseminated intravascular coagulopathy; TEVAR: thoracic endovascular aortic repair. There were 55 (92%) cases that completed the hybrid repair, and the waiting period until TEVAR, excluding the cases of preventive renovisceral debranching and TEVAR performed simultaneously, was 35.2 ± 39.3 days (range 1–185 days). The waiting period from preventing renovisceral debranching to TEVAR was 600 ± 561 days (range 104–1665 days). Regarding TEVAR after renovisceral debranching, the average operation time was 161 ± 82 min (range 63–441 min), and the average stay in the intensive care unit was 1.7 ± 2.7 days (range 0–15 days). Cerebrospinal fluid drainage was performed in 18 (30%) patients at TEVAR. Two (4%) patients with a true aneurysm had spinal cord ischaemia after TEVAR. One of these patients underwent emergency TEVAR, as he went into shock 1 day after undergoing the renovisceral debranching procedure due to an impending rupture. Paraplegia occurred as a result of performing TEVAR under hypotension, and the patient did not recover. Another patient underwent elective TEVAR 4 years after the preventive renovisceral debranching operation. Delayed paraparesis occurred suddenly while walking on postoperative Day 7 of TEVAR. Cerebrospinal drainage and steroid administration were successful, and her paraparesis recovered without any after-effects. Eight cases (15%) with a wide range of aneurysms excluded with stent graft showed a trend toward disseminated intravascular coagulopathy. In-hospital death occurred in 3 cases (5%), including 2 cases of rupture while waiting for TEVAR and 1 myocardial infarction after hybrid TEVAR. Late results The mean follow-up time was 32.9 ± 26.2 months (range 2.6–116.6 months). The follow-up completion rate was 96.7%. The size of the aneurysm was tracked using CT. Late outcomes are summarized in Table 4. Four (7%) patients required an additional treatment. Three (5%) required an additional TEVAR. One had Type I endoleak, 1 had Type III endoleak and the rest had aneurysmal change of the proximal edge of stent graft. During follow up, 4 cases (7%) of Type II endoleak were recognized, and transarterial embolization was performed in 1 case in which enlargement of the aneurysm was confirmed. The others have been followed up intensively using CT. Late mortality was observed in 17 (28%) patients. Two (3%) patients who had not visited the hospital after the preventive renovisceral debranching operation died due to aneurysm rupture. Others died due to pneumonia, malignant tumour, cerebrovascular disease and cardiovascular disease, among other causes. All patients who died were ≥70 years of age. Table 4: Late outcomes Variables Total (%) <70 years of age (%) ≥70 years of age (%) Follow-up period (months) 32.9 31.0 33.7 Endoleak 6 (10) 1 (5) 5 (12)  Type I   additional TEVAR 1 (2) 1 (5) 0  Type II   TEA 1 (2) 0 1 (2)   Follow-up 3 (5) 2 (10) 1 (2)  Type III   Additional TEVAR 1 (2) 0 1 (2) Late mortality 17 (28) 0 17 (41)  Pneumonia 3 (5) 0 3 (7)  Malignancy 3 (5) 0 3 (7)  Aneurysm rupture after preventive debranching 2 (3) 0 2 (5)  Cerebral haemorrhage 2 (3) 0 2 (5)  Heart failure 2 (3) 0 2 (5)  Acute aortic dissection 1 (2) 0 1 (2)  Acute myocardial infarction 1 (2) 0 1 (2)  Renal failure 1 (2) 0 1 (2)  Gastrointestinal bleeding 1 (2) 0 1 (2)  Old age 1 (2) 0 1 (2) Variables Total (%) <70 years of age (%) ≥70 years of age (%) Follow-up period (months) 32.9 31.0 33.7 Endoleak 6 (10) 1 (5) 5 (12)  Type I   additional TEVAR 1 (2) 1 (5) 0  Type II   TEA 1 (2) 0 1 (2)   Follow-up 3 (5) 2 (10) 1 (2)  Type III   Additional TEVAR 1 (2) 0 1 (2) Late mortality 17 (28) 0 17 (41)  Pneumonia 3 (5) 0 3 (7)  Malignancy 3 (5) 0 3 (7)  Aneurysm rupture after preventive debranching 2 (3) 0 2 (5)  Cerebral haemorrhage 2 (3) 0 2 (5)  Heart failure 2 (3) 0 2 (5)  Acute aortic dissection 1 (2) 0 1 (2)  Acute myocardial infarction 1 (2) 0 1 (2)  Renal failure 1 (2) 0 1 (2)  Gastrointestinal bleeding 1 (2) 0 1 (2)  Old age 1 (2) 0 1 (2) TEA: transcatheter arterial embolization; TEVAR: thoracic endovascular aortic repair. Table 4: Late outcomes Variables Total (%) <70 years of age (%) ≥70 years of age (%) Follow-up period (months) 32.9 31.0 33.7 Endoleak 6 (10) 1 (5) 5 (12)  Type I   additional TEVAR 1 (2) 1 (5) 0  Type II   TEA 1 (2) 0 1 (2)   Follow-up 3 (5) 2 (10) 1 (2)  Type III   Additional TEVAR 1 (2) 0 1 (2) Late mortality 17 (28) 0 17 (41)  Pneumonia 3 (5) 0 3 (7)  Malignancy 3 (5) 0 3 (7)  Aneurysm rupture after preventive debranching 2 (3) 0 2 (5)  Cerebral haemorrhage 2 (3) 0 2 (5)  Heart failure 2 (3) 0 2 (5)  Acute aortic dissection 1 (2) 0 1 (2)  Acute myocardial infarction 1 (2) 0 1 (2)  Renal failure 1 (2) 0 1 (2)  Gastrointestinal bleeding 1 (2) 0 1 (2)  Old age 1 (2) 0 1 (2) Variables Total (%) <70 years of age (%) ≥70 years of age (%) Follow-up period (months) 32.9 31.0 33.7 Endoleak 6 (10) 1 (5) 5 (12)  Type I   additional TEVAR 1 (2) 1 (5) 0  Type II   TEA 1 (2) 0 1 (2)   Follow-up 3 (5) 2 (10) 1 (2)  Type III   Additional TEVAR 1 (2) 0 1 (2) Late mortality 17 (28) 0 17 (41)  Pneumonia 3 (5) 0 3 (7)  Malignancy 3 (5) 0 3 (7)  Aneurysm rupture after preventive debranching 2 (3) 0 2 (5)  Cerebral haemorrhage 2 (3) 0 2 (5)  Heart failure 2 (3) 0 2 (5)  Acute aortic dissection 1 (2) 0 1 (2)  Acute myocardial infarction 1 (2) 0 1 (2)  Renal failure 1 (2) 0 1 (2)  Gastrointestinal bleeding 1 (2) 0 1 (2)  Old age 1 (2) 0 1 (2) TEA: transcatheter arterial embolization; TEVAR: thoracic endovascular aortic repair. The mean age of the deceased patients at the time of operation was 80 years. The all-cause survival rate was 75.9% ± 5.6% at 2 years, 65.2% ± 7.0% at 5 years and 43.5% ± 13.4% at 8 years (Fig. 2). Because there were many elderly patients, the long-term all-cause survival rate tended to be low. The survival rate by age is shown in Fig. 3. In the patients younger than 70 years, the survival rate was 94.7% ± 5.1% at 2 years and 94.7% ± 5.1% at 5 years. One patient died of aneurysm rupture while waiting for TEVAR early postoperatively. In the patients aged 70–80 years, the survival rate was 74.5% ± 9.9% at 2 years, 67.7% ± 11.1% at 5 years and 67.7% ± 11.1% at 8 years. In the patients ≥80 years of age, the survival rate was 58.4% ± 11.3% at 2 years, 39.0% ± 1.9% at 5 years and 19.5% ± 11.4% at 8 years. The rates of freedom from aortic events, including aneurysm-related death and additional treatment after hybrid TEVAR, are shown in Fig. 4. The rate of freedom from aortic events was 92.9% ± 3.5% at 2 years, 80.5% ± 7.5% at 5 years and 72.5% ± 10.2% at 8 years. There were no aneurysm-related deaths in the long-term among patients who completed hybrid TEVAR. Figure 2: View largeDownload slide The Kaplan–Meier all-cause survival rate. Pt.: patient. Figure 2: View largeDownload slide The Kaplan–Meier all-cause survival rate. Pt.: patient. Figure 3: View largeDownload slide The Kaplan–Meier all-cause survival rate by age. Pt.: patient. Figure 3: View largeDownload slide The Kaplan–Meier all-cause survival rate by age. Pt.: patient. Figure 4: View largeDownload slide The Kaplan–Meier rate of freedom from aortic events. Pt.: patient. Figure 4: View largeDownload slide The Kaplan–Meier rate of freedom from aortic events. Pt.: patient. DISCUSSION The treatment of TAAA continues to have a high mortality and paraplegia rate. Coselli et al. [9] reported excellent results of 5% for 30-day mortality, and the rate of spinal cord ischaemia was 3.8%; however, in many reports, the mortality rate of open repair exceeds 10% [10, 11]. Furthermore, it was reported that mortality was strongly related to advanced age, with a 30-day mortality rate after elective open surgery exceeding 20% in patients ≥70 years of age [11]. With the spread of endovascular treatment, many hybrid operations combining visceral debranching with TEVAR for TAAAs have been reported. Our renovisceral debranching procedure is associated with a long operation time because of the large number of anastomosis sites, and surgery itself is not considered a minimally invasive modality. When the operation time is the same for both surgical procedures, then you may be able to complete conventional open surgery. However, from the viewpoint of not using extracorporeal circulation and not requiring thoracotomy, it is possible for the elderly and high-risk patients who hesitate to undergo conventional open surgery to withstand such invasive surgery. The long-term outcomes are important to extend the indications to younger patients. If there is a low risk of retreatment due to endoleaks in the long-term period and if the long-term patency of visceral bypass can be safely guaranteed, then this procedure might be considered a good treatment for younger patients. However, further long-term follow-up studies are necessary before any definitive conclusions can be made. Graft patency of renovisceral debranching is important with this procedure. Some reports have assessed the branch graft patency after open repair of TAAAs, reporting a 10-year patency rate of 93–100% [12, 13]. Shahverdyan et al. [14] reported the graft patency rate after renovisceral debranching. Their inflow sites of visceral revascularization originated either from the native artery or from aortic prosthetic grafts, and the long-term patency rate of all grafts was 86.1% at 5 years. In addition, the right renal artery is the most likely to be occluded, and most occlusions appear within 30 days after surgery. We use the retrograde approach from the left leg of the bifurcated graft for renovisceral debranching, and Kansal et al. [15] reported no marked differences in the patency between antegrade and retrograde grafts. In our case, 3 of 223 grafts showed early occlusion, and the early graft patency rate was 98.7%. Although long-term follow-up by contrast CT is insufficient at present, no deaths due to graft occlusion have been reported. Another issue is whether renovisceral debranching from the left leg of the bifurcated graft can provide a sufficient blood flow to each organ. However, there is still no clear evidence concerning the blood flow, and therefore, we use as large a bifurcated graft as possible. Another idea for debranching surgery is to place the bypass between the abdominal aorta and femoral artery with a 10-mm graft. Generally, the iliac arteries become thinner with age, and their properties are worse. This bypass then becomes a good access route for subsequent TEVAR, and there is no risk of iliac arterial injury. The choice of simultaneous or staged TEVAR is an important issue in hybrid repair for TAAAs. When we perform this hybrid procedure in emergency cases of rupture, it is necessary to perform TEVAR simultaneously. However, TEVAR in haemodynamically unstable patients increases the risk of spinal cord ischaemia. Although the main advantage of staged TEVAR is a reduced risk of spinal cord ischaemia [3, 16, 17], in our study, 2 cases of spinal cord ischaemia (1 with paraplegia and 1 with paraparesis) occurred in staged TEVAR. One patient developed paraplegia after TEVAR performed urgently under hypotension, and the other developed late paraparesis on Day 7 after TEVAR. There were no cases of spinal cord ischaemia in the 3 patients who underwent a single-stage procedure. As previously reported [18–20], we also believe it is extremely important for TEVAR to be performed in haemodynamically stable patients. In our facility, TEVAR is performed by local anaesthesia under sedation, so the movements of the legs are confirmed immediately after surgery. We try to keep the mean blood pressure above 80 mmHg during the operation. Bisdas et al. [21] suggested that cerebrospinal fluid drainage is not essential in TEVAR under such circumstances. The main disadvantage of staged TEVAR is the risk of an aneurysmal rupture while waiting for TEVAR, which we actually experienced in 5 cases. Two of them occurred after preventive debranching surgery. Now, depending on the size of the aneurysm, we try to perform TEVAR as soon as possible after the renovisceral debranching operation. In particular, patients are carefully followed up after preventive debranching surgery so as not to miss the timing of the next TEVAR. Since the introduction of specifically designed fenestrated, branched endografts and new standardized endoprostheses in the endovascular field, whether hybrid repair for TAAAs is justified is debatable. Verhoeven et al. [22] published their 10-year experience with fenestrated and branched stent grafts for TAAAs. They reported an in-hospital mortality rate of 9% and a similar rate of spinal cord ischaemia. There were 2 deaths in relation to the aneurysms, and 24% of the patients need reintervention during the follow-up period. Although these results are not particularly good, the results have continually been improving due to advances in devices and endovascular techniques. Treating TAAAs with a total endovascular technique is complicated in procedure, and the use of commercially available devices is limited; this approach is not common now. However, the trend over time is tending toward total endovascular treatment, and these devices will undoubtedly evolve and be used more and more in the years to come. Hybrid repair-combined renovisceral debranching with TEVAR may be applied temporarily until total endovascular procedures become common. However, this hybrid repair will likely remain a standard procedure for a while, as it can be performed in elderly and high-risk patients. Limitations This study has some limitations. Despite our decade of experience, as the number of cases was small in the first few years and targeted superelderly patients, the number of patients may be insufficient for demonstrating whether this hybrid repair is actually effective over a long period of time. In addition, many patients had an impaired renal function, and the evaluation of endoleak and graft patency by contrast CT in the long term is not sufficient. It is necessary to conduct follow-up for a longer period of time in patients who have undergone or will soon be undergoing this surgery. CONCLUSION Although the renovisceral debranching surgery for TAAA is not minimally invasive in terms of surgical invasion beyond bifurcated graft replacement for abdominal aortic aneurysm, elderly patients can withstand this surgical invasion. Although total endovascular treatment, such as a branched stent graft, might supersede this hybrid TEVAR in the future, the renovisceral debranching TEVAR for TAAAs is a better option for elderly patients, redo cases and high-risk patients who hesitate to undergo conventional open surgery. Further long-term follow-up studies are necessary to extend the indications in younger patients. Conflict of interest: none declared. REFERENCES 1 Donas KP , Lachat M , Rancic Z , Oberkofler C , Pfammatter T , Guber I. Early and midterm outcome of a novel technique to simplify the hybrid procedures in the treatment of thoracoabdominal and pararenal aortic aneurysms . J Vasc Surg 2009 ; 50 : 1280 – 4 . Google Scholar CrossRef Search ADS PubMed 2 Drinkwater SL , Böckler D , Eckstein H , Cheshire NJW , Kotelis D , Wolf O et al. . The visceral hybrid repair of thoraco-abdominal aortic aneurysms—a collaborative approach . Eur J Vasc Endovasc Surg 2009 ; 38 : 578 – 85 . Google Scholar CrossRef Search ADS PubMed 3 Kuratani T , Kato M , Shirakawa Y , Shimamura K , Sawa Y. Long-term results of hybrid endovascular repair for thoraco-abdominal aortic aneurysms . Eur Cardiothorac Surg 2010 ; 38 : 299 – 304 . Google Scholar CrossRef Search ADS 4 Hughes GC , Andersen ND , Hanna JM , McCann RL. Thoracoabdominal aortic aneurysm: hybrid repair outcomes . Ann Cardiothorac Surg 2012 ; 1 : 311 – 9 . 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This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

Ten-year experience of the thoraco-abdominal aortic aneurysm treatment using a hybrid thoracic endovascular aortic repair

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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1569-9293
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1569-9285
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10.1093/icvts/ivy021
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Abstract

Abstract OBJECTIVES The treatment of thoraco-abdominal aortic aneurysm continues to have a high mortality and paraplegia rate. In superaging societies, the methods of performing less invasive operations remain a major issue. We reviewed our 10-year experience in the treatment of thoraco-abdominal aortic aneurysm using a hybrid procedure of combined visceral reconstruction and thoracic endovascular aortic repair. METHODS Sixty patients underwent a hybrid repair for the treatment of the thoraco-abdominal aortic aneurysm between 2007 and 2016. The mean age was 72.7 years. A true aneurysm was found in 43 (72%) patients and a chronic dissection in 17 (28%) patients. The standard operative procedure involved replacing the abdominal aorta with an artificial graft, and the visceral arteries were reconstructed using a quadrifurcated graft. Renovisceral debranching and stent grafting were performed as a 2-stage procedure. RESULTS The hospital mortality rate was 5%. Two (3%) patients died due to an aneurysmal rupture in the hospital just after renovisceral debranching. The other 2 patients died due to an aneurysmal rupture in the long-term period after preventive renovisceral debranching. Two (3%) patients experienced spinal cord ischaemia after the stenting procedure. Four (7%) patients required additional treatment during the follow-up period. The overall survival was 75.9% at 2 years, 65.2% at 5 years and 43.5% at 8 years. The rates of freedom from aorta-related events were 92.9% at 2 years, 80.5% at 5 years and 72.5% at 8 years. CONCLUSIONS The hybrid repair is considered to be a good option for elderly and high-risk patients. Further long-term follow-up is necessary to extend the indication in younger patients. Thoraco-abdominal aortic aneurysm, Hybrid thoracic endovascular aortic repair, Renovisceral debranching INTRODUCTION The treatment of thoraco-abdominal aortic aneurysms (TAAAs) is still challenging, as the mortality of conventional open surgery is not very promising when compared with other aortic operations, and the incidence of spinal cord ischaemia, which greatly affects the postoperative quality of life, is relatively high. In Japan, which is becoming a superaging society, the method of performing minimally invasive operations for elderly and high-risk patients remains a major issue. In this era, endovascular aortic repair and thoracic endovascular aortic repair (TEVAR) have developed as minimally invasive surgeries for aortic pathologies. Hybrid repair (renovisceral debranching plus endovascular exclusion) that takes advantage of endovascular treatment has emerged as an alternative operation for the treatment of TAAAs in the endovascular era. Regarding the results, a few reports targeting more than 50 patients have described the mortality rate as 0–24.1% and the incidence of spinal cord ischaemia as 0–8.6% [1–7]. Some of these reports have described medium-term to long-term outcomes of more than 5 years, so there is room for discussion on whether this hybrid repair of TAAAs can be applied to all patients, including young patients. We reviewed our total experience. We classified the patients into 2 groups comprising those <70 and ≥70 years of age and evaluated the early and long-term results obtained from this hybrid procedure. PATIENTS AND METHODS Data source This is a single-centre series of 60 consecutive patients who underwent renovisceral debranching TEVAR for TAAAs between 2007 and 2016. One case in 2007, 1 case in 2008, 3 cases in 2009, 4 cases in 2010, 6 cases in 2011, 10 cases in 2012, 6 cases in 2013, 12 cases in 2014, 8 cases in 2015 and 9 cases in 2016 underwent surgery consisting of hybrid TEVAR. Sixteen patients underwent conventional open TAAAs repair during this period. Regarding patient selection, all patients older than 70 years who were not emergency cases were targeted for hybrid TEVAR between 2007 and 2011. We extended the indication to patients aged 60 years and younger in 2012. This retrospective study was approved by the Institutional Review Board of the Oita University Hospital, and the need for individual patient consent was waived. Treatment strategy of thoraco-abdominal aortic aneurysms We perform the renovisceral debranching operation and TEVAR in 2 stages for TAAAs including chronic dissection with aneurysmal size exceeding 55 mm. When the aneurysmal size is >60 mm, the next TEVAR is performed within a few days after the renovisceral debranching procedure. When the aneurysmal size is <60 mm, the next TEVAR is performed after the recovery of activity of daily living. In addition, when graft replacement for abdominal aortic aneurysm is performed, if there are any aneurysms exceeding 50 mm in size in the thoraco-abdominal region then a renovisceral debranching operation is performed simultaneously, so that TEVAR can be performed in future. We specify this as a preventive renovisceral debranching surgery. Operative procedure A renovisceral debranching operation is performed using median laparotomy. Initially, the visceral branches [celiac trunk, superior mesenteric artery (SMA) and bilateral renal artery] are secured. Normally, the abdominal aorta is replaced with a bifurcated graft. When the abdominal aorta and iliac artery are well characterized and there are no problems with the stent graft’s access or landing, there is no need to intentionally replace the abdominal aorta with an artificial graft. The quadrifurcated graft, known as the ‘InterGard Quattro’ (Getinge Group Japan, Inc., Tokyo, Japan), is anastomosed to the left leg of the bifurcated graft, and the visceral arteries are reconstructed using the quadrifurcated graft. If the patients have previously undergone abdominal aortic repair, re-replacement of the abdominal graft is unnecessary, and a quadrifurcated graft for renovisceral debranch should be anastomosed to the left leg of the existing graft. In our facility, the quadrifurcated graft uses a size of 14 × 7 × 6 mm. The proximal site of the renal artery is cut-off using Hem-o-lok® (Teleflex, Inc., Morrisville, NC, USA) and transected. Renal protection using an injection of 500 ml of chilled bicarbonate Ringer’s solution mixed with D-mannitol, heparin and sodium bicarbonate is achieved for patients with an impaired renal function. The bilateral renal artery is reconstructed with an end-to-end anastomosis of a 6-mm graft. The proximal site of the celiac trunk and SMA are also cut-off using Hem-o-lok® and reconstructed with an end-to-side anastomosis of a 7-mm graft. Finally, we make a bypass between the abdominal graft and the right femoral artery with a 10-mm graft if iliac artery is poorly characterized. This will be the access route for the next TEVAR. A picture of the operative field after abdominal debranching is shown in Fig. 1A. Figure 1: View largeDownload slide (A) A picture of operative field after abdominal debranching. (B) Postoperative 3D computed tomography of renovisceral debranching and thoracic endovascular aortic repair. Figure 1: View largeDownload slide (A) A picture of operative field after abdominal debranching. (B) Postoperative 3D computed tomography of renovisceral debranching and thoracic endovascular aortic repair. Renovisceral debranching and TEVAR are performed as a 2-stage procedure. Normally, TEVAR is performed with local anaesthesia under sedation with intravenous anaesthesia. In such cases, cerebrospinal fluid drainage for spinal cord protection is not absolutely necessary, as blood pressure can be easily kept in a stable state. Vascular access for TEVAR is femoral artery or graft anastomosed to the femoral artery. In TEVAR, various stent grafts are selectively used depending on their features. Completed 3D computed tomography (CT) of renovisceral debranching and TEVAR is shown in Fig. 1B. Postoperative follow-up In all cases, contrast CT was performed for the planning of treatment before surgery. Postoperative patients were evaluated by CT at 1, 6 and 12 months and every year thereafter. Statistical analysis All data are analysed retrospectively. Continuous variables are expressed as the mean ± standard deviation. Categorical variables are presented as the number and percentage. The survival and freedom from aortic events are determined by the Kaplan–Meier methods of estimation. All analyses are performed using the Excel statistical software package (Ekuseru-Toukei 2015; Social Survey Research Information Co., Ltd., Tokyo, Japan). RESULTS Patient demographics Patient demography and comorbidities are summarized in Table 1. Forty-two (70%) patients were men. The mean patient age was 72.7 ± 9.9 years (range 47–89 years). Patients older than 70 years accounted for 68%. There were 49 (82%) patients with hypertension, 25 (42%) with hyperlipidaemia and 9 (15%) with diabetes mellitus. Fifteen (25%) patients had a history of treatment of coronary artery disease, and 7 (12%) patients had cerebrovascular disease. Seventeen (28%) patients had chronic obstructive pulmonary disease; however, there were no patients with domiciliary oxygen therapy. Forty-two (70%) patients showed chronic kidney disease of G3 (30 ≤ estimated glomerular filtration rate < 60) or higher. Fourteen (23%) patients were G3b (30 ≤ estimated glomerular filtration rate < 45), and 9 (15%) were G4 (15 ≤ estimated glomerular filtration rate < 30); however, there were no patients with haemodialysis. Especially, severe renal dysfunction was commonly observed in patients ≥70 years of age. There were no patients with any type of connective tissue disease. Three (13%) patients had a history of cardiac surgery, and 35 (58%) had a history of aortic surgery. The ascending aortic replacement was performed in 1 case (2%), aortic arch replacement in 20 cases (33%), descending aortic replacement in 9 cases (15%) and abdominal aortic replacement in 13 cases (22%). Table 1: Patient demography and comorbidity Variables Total (%) <70 years of age (%) ≥70 years of age (%) Patients 60 (100) 19 (32) 41 (68) Gender  Male 42 (70) 16 (84) 26 (63)  Female 18 (30) 3 (16) 15 (37) Mean age (years) 72.7 60.4 78.4  70s 21 (35) 21 (51)  80s 20 (33) 20 (49) Hypertension 49 (82) 17 (89) 32 (78) Hyperlipidaemia 25 (42) 7 (37) 18 (44) Diabetes mellitus 9 (15) 4 (21) 5 (12) Coronary artery disease 15 (25) 4 (21) 11 (27) Cerebrovascular disease 7 (12) 4 (21) 3 (7) COPD 17 (28) 4 (21) 12 (32) CKD  G3a (45 ≤ eGFR < 60) 19 (32) 4 (21) 15 (37)  G3b (30 ≤ eGFR < 45) 14 (23) 3 (16) 11 (27)  G4 (15 ≤ eGFR < 30) 9 (15) 0 9 (22)  Dialysis 0 0 0 Prior cardiac surgery 8 (13) 4 (21) 4 (12) Prior aortic surgery 35 (58) 13 (68) 22 (54)  Ascending 1 (2) 1 (5) 0  Arch 20 (33) 10 (53) 10 (24)  Descending 9 (15) 3 (16) 6 (15)  Thoraco-abdominal 0 0 0  Abdominal 13 (22) 3 (16) 10 (24) Variables Total (%) <70 years of age (%) ≥70 years of age (%) Patients 60 (100) 19 (32) 41 (68) Gender  Male 42 (70) 16 (84) 26 (63)  Female 18 (30) 3 (16) 15 (37) Mean age (years) 72.7 60.4 78.4  70s 21 (35) 21 (51)  80s 20 (33) 20 (49) Hypertension 49 (82) 17 (89) 32 (78) Hyperlipidaemia 25 (42) 7 (37) 18 (44) Diabetes mellitus 9 (15) 4 (21) 5 (12) Coronary artery disease 15 (25) 4 (21) 11 (27) Cerebrovascular disease 7 (12) 4 (21) 3 (7) COPD 17 (28) 4 (21) 12 (32) CKD  G3a (45 ≤ eGFR < 60) 19 (32) 4 (21) 15 (37)  G3b (30 ≤ eGFR < 45) 14 (23) 3 (16) 11 (27)  G4 (15 ≤ eGFR < 30) 9 (15) 0 9 (22)  Dialysis 0 0 0 Prior cardiac surgery 8 (13) 4 (21) 4 (12) Prior aortic surgery 35 (58) 13 (68) 22 (54)  Ascending 1 (2) 1 (5) 0  Arch 20 (33) 10 (53) 10 (24)  Descending 9 (15) 3 (16) 6 (15)  Thoraco-abdominal 0 0 0  Abdominal 13 (22) 3 (16) 10 (24) COPD: chronic obstructive pulmonary disease; CKD: chronic kidney disease; eGFR: estimated glomerular filtration rate. Table 1: Patient demography and comorbidity Variables Total (%) <70 years of age (%) ≥70 years of age (%) Patients 60 (100) 19 (32) 41 (68) Gender  Male 42 (70) 16 (84) 26 (63)  Female 18 (30) 3 (16) 15 (37) Mean age (years) 72.7 60.4 78.4  70s 21 (35) 21 (51)  80s 20 (33) 20 (49) Hypertension 49 (82) 17 (89) 32 (78) Hyperlipidaemia 25 (42) 7 (37) 18 (44) Diabetes mellitus 9 (15) 4 (21) 5 (12) Coronary artery disease 15 (25) 4 (21) 11 (27) Cerebrovascular disease 7 (12) 4 (21) 3 (7) COPD 17 (28) 4 (21) 12 (32) CKD  G3a (45 ≤ eGFR < 60) 19 (32) 4 (21) 15 (37)  G3b (30 ≤ eGFR < 45) 14 (23) 3 (16) 11 (27)  G4 (15 ≤ eGFR < 30) 9 (15) 0 9 (22)  Dialysis 0 0 0 Prior cardiac surgery 8 (13) 4 (21) 4 (12) Prior aortic surgery 35 (58) 13 (68) 22 (54)  Ascending 1 (2) 1 (5) 0  Arch 20 (33) 10 (53) 10 (24)  Descending 9 (15) 3 (16) 6 (15)  Thoraco-abdominal 0 0 0  Abdominal 13 (22) 3 (16) 10 (24) Variables Total (%) <70 years of age (%) ≥70 years of age (%) Patients 60 (100) 19 (32) 41 (68) Gender  Male 42 (70) 16 (84) 26 (63)  Female 18 (30) 3 (16) 15 (37) Mean age (years) 72.7 60.4 78.4  70s 21 (35) 21 (51)  80s 20 (33) 20 (49) Hypertension 49 (82) 17 (89) 32 (78) Hyperlipidaemia 25 (42) 7 (37) 18 (44) Diabetes mellitus 9 (15) 4 (21) 5 (12) Coronary artery disease 15 (25) 4 (21) 11 (27) Cerebrovascular disease 7 (12) 4 (21) 3 (7) COPD 17 (28) 4 (21) 12 (32) CKD  G3a (45 ≤ eGFR < 60) 19 (32) 4 (21) 15 (37)  G3b (30 ≤ eGFR < 45) 14 (23) 3 (16) 11 (27)  G4 (15 ≤ eGFR < 30) 9 (15) 0 9 (22)  Dialysis 0 0 0 Prior cardiac surgery 8 (13) 4 (21) 4 (12) Prior aortic surgery 35 (58) 13 (68) 22 (54)  Ascending 1 (2) 1 (5) 0  Arch 20 (33) 10 (53) 10 (24)  Descending 9 (15) 3 (16) 6 (15)  Thoraco-abdominal 0 0 0  Abdominal 13 (22) 3 (16) 10 (24) COPD: chronic obstructive pulmonary disease; CKD: chronic kidney disease; eGFR: estimated glomerular filtration rate. Preoperative aortic characteristics The aortic characteristics are summarized in Table 2. Aortic pathologies included 43 (72%) degenerative aneurysms and 17 (28%) chronic aortic dissection. Chronic dissection was frequently observed in patients younger than 70 years, whereas the occurrence of a true aneurysm frequently identified in patients ≥70 years of age. The mean aneurysmal size was 58.7 ± 7.1 mm (range 49–86 mm). Aneurysms were classified according to the modified Crawford classification [8]. Type V was the most frequent and found in 24 cases. Among them, 11 cases were complicated by an abdominal aortic aneurysm. In addition, Type I was found in 12 cases (20%), Type II in 8 cases (13%), Type III in 10 cases (17%) and Type IV in 6 cases (10%). There were 5 (8%) emergency and urgent operations. In 1 emergency case of an aneurysmal rupture and 2 urgent cases of an impending aneurysmal rupture, renovisceral debranching and TEVAR were performed simultaneously. In 2 urgent cases of an impending aneurysmal rupture, renovisceral debranching and TEVAR were performed separately. Table 2: Aortic characteristics Variables Total (%) <70 years of age (%) ≥70 years of age (%) Mean aneurysmal size (mm) 58.7 58.2 59.0 Aortic pathologies  Degenerative aortic disease 43 (72) 6 (32) 37 (90)  Chronic aortic dissection 17 (28) 13 (68) 4 (10) Crawford classification (modified)  Type I 12 (20) 2 (11) 10 (24)  Type II 8 (13) 8 (42) 0  Type III 10 (17) 6 (31) 4 (10)  Type IV 6 (10) 1 (5) 5 (12)  Type V 24 (40) 2 (11) 22 (54) Variables Total (%) <70 years of age (%) ≥70 years of age (%) Mean aneurysmal size (mm) 58.7 58.2 59.0 Aortic pathologies  Degenerative aortic disease 43 (72) 6 (32) 37 (90)  Chronic aortic dissection 17 (28) 13 (68) 4 (10) Crawford classification (modified)  Type I 12 (20) 2 (11) 10 (24)  Type II 8 (13) 8 (42) 0  Type III 10 (17) 6 (31) 4 (10)  Type IV 6 (10) 1 (5) 5 (12)  Type V 24 (40) 2 (11) 22 (54) Table 2: Aortic characteristics Variables Total (%) <70 years of age (%) ≥70 years of age (%) Mean aneurysmal size (mm) 58.7 58.2 59.0 Aortic pathologies  Degenerative aortic disease 43 (72) 6 (32) 37 (90)  Chronic aortic dissection 17 (28) 13 (68) 4 (10) Crawford classification (modified)  Type I 12 (20) 2 (11) 10 (24)  Type II 8 (13) 8 (42) 0  Type III 10 (17) 6 (31) 4 (10)  Type IV 6 (10) 1 (5) 5 (12)  Type V 24 (40) 2 (11) 22 (54) Variables Total (%) <70 years of age (%) ≥70 years of age (%) Mean aneurysmal size (mm) 58.7 58.2 59.0 Aortic pathologies  Degenerative aortic disease 43 (72) 6 (32) 37 (90)  Chronic aortic dissection 17 (28) 13 (68) 4 (10) Crawford classification (modified)  Type I 12 (20) 2 (11) 10 (24)  Type II 8 (13) 8 (42) 0  Type III 10 (17) 6 (31) 4 (10)  Type IV 6 (10) 1 (5) 5 (12)  Type V 24 (40) 2 (11) 22 (54) Early results In 60 cases, the debranching procedure was performed. A preventive renovisceral debranching procedure was performed in 10 (17%) of them. Regarding the renovisceral debranching procedure, the average operation time was 537 ± 120 min (range 305–840 min). The average number of anastomosis sites was 8.6 ± 2.2 (range 5–14). The average amount of bleeding was 2033 ± 1218 ml (range 500–4900 ml). Most patients required blood transfusions. The average stay in the intensive care unit was 3.6 ± 2.8 days (range 0–16 days). Early outcomes are summarized in Table 3. One patient with a true aneurysm had paraplegia after the renovisceral debranching operation though the cause was unknown. The patient died due to an aneurysmal rupture during hyperbaric oxygen therapy for the paraplegia. In addition to this patient, 2 cases of an aneurysmal rupture occurred while waiting for TEVAR. One case was rescued with emergency TEVAR, but another case resulted in death. Four cases (7%) of anastomotic haemorrhaging were found, and embolization and open haemostasis were performed. One (2%) patient who had CKD G4 before surgery newly started maintenance dialysis after the renovisceral debranching operation. Although 5 (8%) patients needed transient dialysis with continuous haemodiafiltration in the intensive care unit, everyone got off transient dialysis. Gastrointestinal dysfunction, such as intestinal obstruction and diarrhoea, was found in 6 (10%) patients. There were no respiratory complications. The total amount of visceral bypass grafts was 223. Quadruple bypasses (celiac, SMA and bilateral renal) were performed in 48 cases (80%). Triple bypasses (celiac, SMA and lateral renal: 4 and SMA and bilateral renal: 3) were performed in 7 cases (12%). Double bypasses (celiac and SMA) were performed in 5 cases (8%). Three of 223 grafts showed early occlusion, for an early graft patency rate of 98.7%. Twenty-one (35%) patients were evaluated by contrast CT for more than 1 year. The average follow-up period was 29.6 ± 14.2 months (range 12–60 months), in which there was no bypass late occlusion. Table 3: Early outcomes Variables Total (%) <70 years of age (%) ≥70 years of age (%) Major complications after renovisceral debranching  Aneurysm rupture while waiting for TEVAR 3 (5) 1 (5) 2 (5)  Paraplegia 1 (2) 1 (5) 0  Bleeding of anastomosis site 4 (7) 1 (5) 3 (7)  Newly maintenance dialysis 1 (2) 0 1 (2)  Occlusion of reconstructed renovisceral branch 3 (5) 0 3 (7)   Celiac trunk 2 (4) 0 2 (5)   Right renal artery 1 (2) 0 1 (2)  Respiratory dysfunction 0 0 0 Major complications after TEVAR  Paraplegia 2 (4) 0 2 (5)  DIC (bleeding tendency) 8 (15) 4 (21) 4 (10) Hospital mortality 3 (5) 1 (5) 2 (5)  Aneurysm rupture while waiting for TEVAR 2 (3) 1 (5) 1 (2)  Acute myocardial infarction 1 (2) 0 1 (2) Variables Total (%) <70 years of age (%) ≥70 years of age (%) Major complications after renovisceral debranching  Aneurysm rupture while waiting for TEVAR 3 (5) 1 (5) 2 (5)  Paraplegia 1 (2) 1 (5) 0  Bleeding of anastomosis site 4 (7) 1 (5) 3 (7)  Newly maintenance dialysis 1 (2) 0 1 (2)  Occlusion of reconstructed renovisceral branch 3 (5) 0 3 (7)   Celiac trunk 2 (4) 0 2 (5)   Right renal artery 1 (2) 0 1 (2)  Respiratory dysfunction 0 0 0 Major complications after TEVAR  Paraplegia 2 (4) 0 2 (5)  DIC (bleeding tendency) 8 (15) 4 (21) 4 (10) Hospital mortality 3 (5) 1 (5) 2 (5)  Aneurysm rupture while waiting for TEVAR 2 (3) 1 (5) 1 (2)  Acute myocardial infarction 1 (2) 0 1 (2) DIC: disseminated intravascular coagulopathy; TEVAR: thoracic endovascular aortic repair. Table 3: Early outcomes Variables Total (%) <70 years of age (%) ≥70 years of age (%) Major complications after renovisceral debranching  Aneurysm rupture while waiting for TEVAR 3 (5) 1 (5) 2 (5)  Paraplegia 1 (2) 1 (5) 0  Bleeding of anastomosis site 4 (7) 1 (5) 3 (7)  Newly maintenance dialysis 1 (2) 0 1 (2)  Occlusion of reconstructed renovisceral branch 3 (5) 0 3 (7)   Celiac trunk 2 (4) 0 2 (5)   Right renal artery 1 (2) 0 1 (2)  Respiratory dysfunction 0 0 0 Major complications after TEVAR  Paraplegia 2 (4) 0 2 (5)  DIC (bleeding tendency) 8 (15) 4 (21) 4 (10) Hospital mortality 3 (5) 1 (5) 2 (5)  Aneurysm rupture while waiting for TEVAR 2 (3) 1 (5) 1 (2)  Acute myocardial infarction 1 (2) 0 1 (2) Variables Total (%) <70 years of age (%) ≥70 years of age (%) Major complications after renovisceral debranching  Aneurysm rupture while waiting for TEVAR 3 (5) 1 (5) 2 (5)  Paraplegia 1 (2) 1 (5) 0  Bleeding of anastomosis site 4 (7) 1 (5) 3 (7)  Newly maintenance dialysis 1 (2) 0 1 (2)  Occlusion of reconstructed renovisceral branch 3 (5) 0 3 (7)   Celiac trunk 2 (4) 0 2 (5)   Right renal artery 1 (2) 0 1 (2)  Respiratory dysfunction 0 0 0 Major complications after TEVAR  Paraplegia 2 (4) 0 2 (5)  DIC (bleeding tendency) 8 (15) 4 (21) 4 (10) Hospital mortality 3 (5) 1 (5) 2 (5)  Aneurysm rupture while waiting for TEVAR 2 (3) 1 (5) 1 (2)  Acute myocardial infarction 1 (2) 0 1 (2) DIC: disseminated intravascular coagulopathy; TEVAR: thoracic endovascular aortic repair. There were 55 (92%) cases that completed the hybrid repair, and the waiting period until TEVAR, excluding the cases of preventive renovisceral debranching and TEVAR performed simultaneously, was 35.2 ± 39.3 days (range 1–185 days). The waiting period from preventing renovisceral debranching to TEVAR was 600 ± 561 days (range 104–1665 days). Regarding TEVAR after renovisceral debranching, the average operation time was 161 ± 82 min (range 63–441 min), and the average stay in the intensive care unit was 1.7 ± 2.7 days (range 0–15 days). Cerebrospinal fluid drainage was performed in 18 (30%) patients at TEVAR. Two (4%) patients with a true aneurysm had spinal cord ischaemia after TEVAR. One of these patients underwent emergency TEVAR, as he went into shock 1 day after undergoing the renovisceral debranching procedure due to an impending rupture. Paraplegia occurred as a result of performing TEVAR under hypotension, and the patient did not recover. Another patient underwent elective TEVAR 4 years after the preventive renovisceral debranching operation. Delayed paraparesis occurred suddenly while walking on postoperative Day 7 of TEVAR. Cerebrospinal drainage and steroid administration were successful, and her paraparesis recovered without any after-effects. Eight cases (15%) with a wide range of aneurysms excluded with stent graft showed a trend toward disseminated intravascular coagulopathy. In-hospital death occurred in 3 cases (5%), including 2 cases of rupture while waiting for TEVAR and 1 myocardial infarction after hybrid TEVAR. Late results The mean follow-up time was 32.9 ± 26.2 months (range 2.6–116.6 months). The follow-up completion rate was 96.7%. The size of the aneurysm was tracked using CT. Late outcomes are summarized in Table 4. Four (7%) patients required an additional treatment. Three (5%) required an additional TEVAR. One had Type I endoleak, 1 had Type III endoleak and the rest had aneurysmal change of the proximal edge of stent graft. During follow up, 4 cases (7%) of Type II endoleak were recognized, and transarterial embolization was performed in 1 case in which enlargement of the aneurysm was confirmed. The others have been followed up intensively using CT. Late mortality was observed in 17 (28%) patients. Two (3%) patients who had not visited the hospital after the preventive renovisceral debranching operation died due to aneurysm rupture. Others died due to pneumonia, malignant tumour, cerebrovascular disease and cardiovascular disease, among other causes. All patients who died were ≥70 years of age. Table 4: Late outcomes Variables Total (%) <70 years of age (%) ≥70 years of age (%) Follow-up period (months) 32.9 31.0 33.7 Endoleak 6 (10) 1 (5) 5 (12)  Type I   additional TEVAR 1 (2) 1 (5) 0  Type II   TEA 1 (2) 0 1 (2)   Follow-up 3 (5) 2 (10) 1 (2)  Type III   Additional TEVAR 1 (2) 0 1 (2) Late mortality 17 (28) 0 17 (41)  Pneumonia 3 (5) 0 3 (7)  Malignancy 3 (5) 0 3 (7)  Aneurysm rupture after preventive debranching 2 (3) 0 2 (5)  Cerebral haemorrhage 2 (3) 0 2 (5)  Heart failure 2 (3) 0 2 (5)  Acute aortic dissection 1 (2) 0 1 (2)  Acute myocardial infarction 1 (2) 0 1 (2)  Renal failure 1 (2) 0 1 (2)  Gastrointestinal bleeding 1 (2) 0 1 (2)  Old age 1 (2) 0 1 (2) Variables Total (%) <70 years of age (%) ≥70 years of age (%) Follow-up period (months) 32.9 31.0 33.7 Endoleak 6 (10) 1 (5) 5 (12)  Type I   additional TEVAR 1 (2) 1 (5) 0  Type II   TEA 1 (2) 0 1 (2)   Follow-up 3 (5) 2 (10) 1 (2)  Type III   Additional TEVAR 1 (2) 0 1 (2) Late mortality 17 (28) 0 17 (41)  Pneumonia 3 (5) 0 3 (7)  Malignancy 3 (5) 0 3 (7)  Aneurysm rupture after preventive debranching 2 (3) 0 2 (5)  Cerebral haemorrhage 2 (3) 0 2 (5)  Heart failure 2 (3) 0 2 (5)  Acute aortic dissection 1 (2) 0 1 (2)  Acute myocardial infarction 1 (2) 0 1 (2)  Renal failure 1 (2) 0 1 (2)  Gastrointestinal bleeding 1 (2) 0 1 (2)  Old age 1 (2) 0 1 (2) TEA: transcatheter arterial embolization; TEVAR: thoracic endovascular aortic repair. Table 4: Late outcomes Variables Total (%) <70 years of age (%) ≥70 years of age (%) Follow-up period (months) 32.9 31.0 33.7 Endoleak 6 (10) 1 (5) 5 (12)  Type I   additional TEVAR 1 (2) 1 (5) 0  Type II   TEA 1 (2) 0 1 (2)   Follow-up 3 (5) 2 (10) 1 (2)  Type III   Additional TEVAR 1 (2) 0 1 (2) Late mortality 17 (28) 0 17 (41)  Pneumonia 3 (5) 0 3 (7)  Malignancy 3 (5) 0 3 (7)  Aneurysm rupture after preventive debranching 2 (3) 0 2 (5)  Cerebral haemorrhage 2 (3) 0 2 (5)  Heart failure 2 (3) 0 2 (5)  Acute aortic dissection 1 (2) 0 1 (2)  Acute myocardial infarction 1 (2) 0 1 (2)  Renal failure 1 (2) 0 1 (2)  Gastrointestinal bleeding 1 (2) 0 1 (2)  Old age 1 (2) 0 1 (2) Variables Total (%) <70 years of age (%) ≥70 years of age (%) Follow-up period (months) 32.9 31.0 33.7 Endoleak 6 (10) 1 (5) 5 (12)  Type I   additional TEVAR 1 (2) 1 (5) 0  Type II   TEA 1 (2) 0 1 (2)   Follow-up 3 (5) 2 (10) 1 (2)  Type III   Additional TEVAR 1 (2) 0 1 (2) Late mortality 17 (28) 0 17 (41)  Pneumonia 3 (5) 0 3 (7)  Malignancy 3 (5) 0 3 (7)  Aneurysm rupture after preventive debranching 2 (3) 0 2 (5)  Cerebral haemorrhage 2 (3) 0 2 (5)  Heart failure 2 (3) 0 2 (5)  Acute aortic dissection 1 (2) 0 1 (2)  Acute myocardial infarction 1 (2) 0 1 (2)  Renal failure 1 (2) 0 1 (2)  Gastrointestinal bleeding 1 (2) 0 1 (2)  Old age 1 (2) 0 1 (2) TEA: transcatheter arterial embolization; TEVAR: thoracic endovascular aortic repair. The mean age of the deceased patients at the time of operation was 80 years. The all-cause survival rate was 75.9% ± 5.6% at 2 years, 65.2% ± 7.0% at 5 years and 43.5% ± 13.4% at 8 years (Fig. 2). Because there were many elderly patients, the long-term all-cause survival rate tended to be low. The survival rate by age is shown in Fig. 3. In the patients younger than 70 years, the survival rate was 94.7% ± 5.1% at 2 years and 94.7% ± 5.1% at 5 years. One patient died of aneurysm rupture while waiting for TEVAR early postoperatively. In the patients aged 70–80 years, the survival rate was 74.5% ± 9.9% at 2 years, 67.7% ± 11.1% at 5 years and 67.7% ± 11.1% at 8 years. In the patients ≥80 years of age, the survival rate was 58.4% ± 11.3% at 2 years, 39.0% ± 1.9% at 5 years and 19.5% ± 11.4% at 8 years. The rates of freedom from aortic events, including aneurysm-related death and additional treatment after hybrid TEVAR, are shown in Fig. 4. The rate of freedom from aortic events was 92.9% ± 3.5% at 2 years, 80.5% ± 7.5% at 5 years and 72.5% ± 10.2% at 8 years. There were no aneurysm-related deaths in the long-term among patients who completed hybrid TEVAR. Figure 2: View largeDownload slide The Kaplan–Meier all-cause survival rate. Pt.: patient. Figure 2: View largeDownload slide The Kaplan–Meier all-cause survival rate. Pt.: patient. Figure 3: View largeDownload slide The Kaplan–Meier all-cause survival rate by age. Pt.: patient. Figure 3: View largeDownload slide The Kaplan–Meier all-cause survival rate by age. Pt.: patient. Figure 4: View largeDownload slide The Kaplan–Meier rate of freedom from aortic events. Pt.: patient. Figure 4: View largeDownload slide The Kaplan–Meier rate of freedom from aortic events. Pt.: patient. DISCUSSION The treatment of TAAA continues to have a high mortality and paraplegia rate. Coselli et al. [9] reported excellent results of 5% for 30-day mortality, and the rate of spinal cord ischaemia was 3.8%; however, in many reports, the mortality rate of open repair exceeds 10% [10, 11]. Furthermore, it was reported that mortality was strongly related to advanced age, with a 30-day mortality rate after elective open surgery exceeding 20% in patients ≥70 years of age [11]. With the spread of endovascular treatment, many hybrid operations combining visceral debranching with TEVAR for TAAAs have been reported. Our renovisceral debranching procedure is associated with a long operation time because of the large number of anastomosis sites, and surgery itself is not considered a minimally invasive modality. When the operation time is the same for both surgical procedures, then you may be able to complete conventional open surgery. However, from the viewpoint of not using extracorporeal circulation and not requiring thoracotomy, it is possible for the elderly and high-risk patients who hesitate to undergo conventional open surgery to withstand such invasive surgery. The long-term outcomes are important to extend the indications to younger patients. If there is a low risk of retreatment due to endoleaks in the long-term period and if the long-term patency of visceral bypass can be safely guaranteed, then this procedure might be considered a good treatment for younger patients. However, further long-term follow-up studies are necessary before any definitive conclusions can be made. Graft patency of renovisceral debranching is important with this procedure. Some reports have assessed the branch graft patency after open repair of TAAAs, reporting a 10-year patency rate of 93–100% [12, 13]. Shahverdyan et al. [14] reported the graft patency rate after renovisceral debranching. Their inflow sites of visceral revascularization originated either from the native artery or from aortic prosthetic grafts, and the long-term patency rate of all grafts was 86.1% at 5 years. In addition, the right renal artery is the most likely to be occluded, and most occlusions appear within 30 days after surgery. We use the retrograde approach from the left leg of the bifurcated graft for renovisceral debranching, and Kansal et al. [15] reported no marked differences in the patency between antegrade and retrograde grafts. In our case, 3 of 223 grafts showed early occlusion, and the early graft patency rate was 98.7%. Although long-term follow-up by contrast CT is insufficient at present, no deaths due to graft occlusion have been reported. Another issue is whether renovisceral debranching from the left leg of the bifurcated graft can provide a sufficient blood flow to each organ. However, there is still no clear evidence concerning the blood flow, and therefore, we use as large a bifurcated graft as possible. Another idea for debranching surgery is to place the bypass between the abdominal aorta and femoral artery with a 10-mm graft. Generally, the iliac arteries become thinner with age, and their properties are worse. This bypass then becomes a good access route for subsequent TEVAR, and there is no risk of iliac arterial injury. The choice of simultaneous or staged TEVAR is an important issue in hybrid repair for TAAAs. When we perform this hybrid procedure in emergency cases of rupture, it is necessary to perform TEVAR simultaneously. However, TEVAR in haemodynamically unstable patients increases the risk of spinal cord ischaemia. Although the main advantage of staged TEVAR is a reduced risk of spinal cord ischaemia [3, 16, 17], in our study, 2 cases of spinal cord ischaemia (1 with paraplegia and 1 with paraparesis) occurred in staged TEVAR. One patient developed paraplegia after TEVAR performed urgently under hypotension, and the other developed late paraparesis on Day 7 after TEVAR. There were no cases of spinal cord ischaemia in the 3 patients who underwent a single-stage procedure. As previously reported [18–20], we also believe it is extremely important for TEVAR to be performed in haemodynamically stable patients. In our facility, TEVAR is performed by local anaesthesia under sedation, so the movements of the legs are confirmed immediately after surgery. We try to keep the mean blood pressure above 80 mmHg during the operation. Bisdas et al. [21] suggested that cerebrospinal fluid drainage is not essential in TEVAR under such circumstances. The main disadvantage of staged TEVAR is the risk of an aneurysmal rupture while waiting for TEVAR, which we actually experienced in 5 cases. Two of them occurred after preventive debranching surgery. Now, depending on the size of the aneurysm, we try to perform TEVAR as soon as possible after the renovisceral debranching operation. In particular, patients are carefully followed up after preventive debranching surgery so as not to miss the timing of the next TEVAR. Since the introduction of specifically designed fenestrated, branched endografts and new standardized endoprostheses in the endovascular field, whether hybrid repair for TAAAs is justified is debatable. Verhoeven et al. [22] published their 10-year experience with fenestrated and branched stent grafts for TAAAs. They reported an in-hospital mortality rate of 9% and a similar rate of spinal cord ischaemia. There were 2 deaths in relation to the aneurysms, and 24% of the patients need reintervention during the follow-up period. Although these results are not particularly good, the results have continually been improving due to advances in devices and endovascular techniques. Treating TAAAs with a total endovascular technique is complicated in procedure, and the use of commercially available devices is limited; this approach is not common now. However, the trend over time is tending toward total endovascular treatment, and these devices will undoubtedly evolve and be used more and more in the years to come. Hybrid repair-combined renovisceral debranching with TEVAR may be applied temporarily until total endovascular procedures become common. However, this hybrid repair will likely remain a standard procedure for a while, as it can be performed in elderly and high-risk patients. Limitations This study has some limitations. Despite our decade of experience, as the number of cases was small in the first few years and targeted superelderly patients, the number of patients may be insufficient for demonstrating whether this hybrid repair is actually effective over a long period of time. In addition, many patients had an impaired renal function, and the evaluation of endoleak and graft patency by contrast CT in the long term is not sufficient. It is necessary to conduct follow-up for a longer period of time in patients who have undergone or will soon be undergoing this surgery. CONCLUSION Although the renovisceral debranching surgery for TAAA is not minimally invasive in terms of surgical invasion beyond bifurcated graft replacement for abdominal aortic aneurysm, elderly patients can withstand this surgical invasion. Although total endovascular treatment, such as a branched stent graft, might supersede this hybrid TEVAR in the future, the renovisceral debranching TEVAR for TAAAs is a better option for elderly patients, redo cases and high-risk patients who hesitate to undergo conventional open surgery. Further long-term follow-up studies are necessary to extend the indications in younger patients. Conflict of interest: none declared. 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This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Interactive CardioVascular and Thoracic SurgeryOxford University Press

Published: Feb 2, 2018

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