Visceral debranchingand stenting (hybrid) for

complex AAA repair

Ahmad Gamal.

Professor of vascular surgery

Cairo University.

Disclosure

• Speaker name:

.................................................................................

• I have the following potential conflicts of interest to report:

• Consulting

• Employment in industry

• Stockholder of a healthcare company

• Owner of a healthcare company

• Other(s)

• I do not have any potential conflict of interest

The term ‘complex aneurysm’ refers toaneurysms of the upper abdominal aorta thatinvolve any combination of its visceral branchessuch as renal, superior mesenteric or coeliacvessels

Complex aortic aneurysm

Tre

atm

en

t o

pti

on

s

Open repair

Hybrid

Endovascular

(T-branch/chimney/fenestration)

Open repair

• safe, effective, and durable inthe long-term

• Perioperative mortality:

JAA: < 7%

TAAA: 6-40%

• Supra renal/ aortic crossclamping.

• Renal dysfunction: 10 – 40%

Endovascular repair

• Using chimney, fenestrated and branched grafts

• Decreased the operative mortality (5-10%).

• Complex and require very sophisticated endovascular equipment and skills.

• Limited availability

• High cost

• Durability?

Visceral hybrid debranching

Advantages

1) No thoracotomy:

i. fewer pulmonary complications

ii. fewer cardiac arrhythmias

iii. less pain.

2) Reduced hypothermia with subsequent reduction in:

i. coagulopathy;

ii. cardiovascular instability.

3) Applicable to a wide range of patient anatomy

Advantages

4) Reduced duration of mesenteric and visceral ischemia with reduction in:

i. acidosis

ii. gut bacteria translocation/sepsis;

iii. renal failure/use of renal replacement therapy.

5) Less blood loss/reduced transfusion requirement.

6) More patients can be treated where some comorbidities previously excluded them.

Surgical steps

• Anesthesia : General

• Position : Supine

• Incision : Midline transperitoneal / Para-rectal retroperitoneal

• Exposure of Lt. renal , SMA, and celiac arteries.

• Then exposure of the Rt. Renal artery

• Then exposure of both CIAs

Visceral Hybrid Procedure

Octopus Graft

Gustavo S. Oderich, MD1, Bernardo C. Mendes, MD1, Peter Gloviczki, MD1,Manju Kalra, MD1, Audra A. Duncan, MD1 and Thomas C. Bower, MD1

• Maximizes distal landing zone in short CIA.

Case 1

LT CIA

SMA Graft

Celiac Graft

LT Renal Graft

SMA Graft

RT Renal

RT CIA

Case 2

Case 3

LT CIA

SMA graft

LT Renal

RT CIA

RT Renal

We are still collecting our data about hybrid procedures but the preliminary results :

• No: 14

• Mortality: 7%

• Paraplegia: 0%

• Endoleak: 7%

• Graft patency: 93%

Systematic review & Meta-analysis

Bakoyiannis et al(2009)

Moulakakis et al (2011)

No of patients

108 / 15 507 / 19

30 days mortality

10% 12%

paraplegia 3% 4.5%

Endoleak 20% 22%

Graft patency

97% 96%

Bakoyiannis et al. Hybrid procedures in the treatment of thoracoabdominal aortic aneurysms: a

systematic review. J Endovasc Ther. 2009;16:443-450.

Moulakakis et al. Hybrid open endovascular technique for aortic thoracoabdominal pathologies.

Circulation. 2011;124:2670-2680.

North American Complex Abdominal Aortic Debranching Registry (2011)

• 208 patients / 14 academic center

• 163 TAAA / 45 pararenal aneurysms.

• 30 days mortality: 14% (16% TAAA, 9% pararenal)

• Paraplegia: 10%

• Endoleak: 13%

• Graft patency: primary 90% / 1 year 85%.

Conclousion

• Hybrid repair may offer a viable alternative for patients atslightly higher than average operative risk, or for those who haveisolated high risk comorbidities (i.e. chronic lung disease).

• Hybrid surgery will always remain a method of treating thiscomplex and life-threatening disease particularly in individualswith unfavorable anatomy.

• Hybrid repair should be considered in patient with complex aorticaneurysm who are unsuitable to endovascular repair or incenters who have difficulty accessing FBSG.