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Ultra-Hybrid Repair: Open Thoracoabdominal Completion After Descending Stent Grafting

  • Matthew A. Thompson
    Affiliations
    Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
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  • Ashley M. Lowry
    Affiliations
    Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
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  • Francis Caputo
    Affiliations
    Aorta Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio

    Department of Vascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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  • Douglas R. Johnston
    Affiliations
    Aorta Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio

    Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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  • Christopher Smolock
    Affiliations
    Aorta Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio

    Department of Vascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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  • Patrick Vargo
    Affiliations
    Aorta Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio

    Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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  • Eugene H. Blackstone
    Affiliations
    Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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  • Eric E. Roselli
    Correspondence
    Address reprint requests to Eric E. Roselli, MD, Cleveland Clinic, Department of Thoracic and Cardiovascular Surgery, 9500 Euclid Avenue/Desk J4-1, Cleveland, OH 44195. Phone: (216) 444-0995; Fax: (216) 636-0991.
    Affiliations
    Aorta Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio

    Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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  • Collaborators in the Cleveland Clinic Aorta Center
Published:October 12, 2022DOI:https://doi.org/10.1053/j.semtcvs.2022.10.004
      To characterize patient risk profiles and outcomes associated with staged ultra-hybrid repair of extensive aortic disease, in which open thoracoabdominal completion was performed after thoracic stent grafting. From 1/2006 to 1/2021, 92 patients underwent open thoracoabdominal repair of chronic dissection (n=58, 63%), degenerative aneurysm (n=28, 30%), endoleak (n=4, 4.3%), or symptomatic acute type B dissection (n=2, 2.2%) after descending thoracic stent grafting (69, 75%), frozen elephant trunk (5, 5%), or both (18, 20%). The surgical graft was sewn to the distal endovascular device in situ, reducing the extent of the open procedure and eliminating the need for hypothermic circulatory arrest. Mean age was 58±13 years, 89 (97%) were hypertensive, 38 (43%) had chronic obstructive pulmonary disease, 63 (72%) were smokers, 20 (24%) had a prior stroke, and 33 (36%) had a suspected or confirmed heritable aortic condition. Hospital mortality was 7.6% (n=7). Complications included dialysis (16, 20%), tracheostomy (8, 8.7%), stroke (5, 5.7%), and permanent paralysis (6, 6.9%). Survival at 1, 3, and 5 years was 80%, 71%, and 66%, respectively. Mortality was associated with higher blood urea nitrogen and longer distance between the distal endograft edge and proximal patent visceral vessel (P=0.004 and .01, respectively). Patients with extensive aortic disease undergoing open aortic repair after thoracic stent grafting are often young with chronic dissection, multiple comorbidities, or a heritable aortic condition. Success of staged ultra-hybrid operations demonstrates open and endovascular repair strategies are complementary, even when performed in a high-risk patient population.

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      Linked Article

      • Commentary: A Tale of Two Operations
        Seminars in Thoracic and Cardiovascular Surgery
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          Ultra-hybrid repair of thoracoabdominal aortic aneurysms (TAAAs) involves endovascular stenting of the descending thoracic aorta followed by distal open completion with a graft sutured to the distal end of the endograft.1 Hypothesized benefits include avoiding deep hypothermic circulatory arrest (DHCA) and decreasing spinal cord ischemia by allowing vascular collateralization between operations, as demonstrated in porcine models.2,3 Thompson et al. evaluate their single-center experience with ultra-hybrid repair among 92 patients undergoing open TAAA repair after prior stenting in the descending thoracic aorta with thoracic endovascular aneurysm repair (75%, n = 69), frozen elephant trunk (5.4%, n = 5), or both (20%, n = 18).
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