December 12, 2008

HYBRID THORACIC ENDOVASCULAR AORTIC REPAIR (TEVAR): ARE WE PUSHING THE ENVELOPE TOO FAR?

Houssam K. Younes, MD¹, Kristofer M. Charlton-Ouw, MD¹, Patricia W. Harris, BA², Jean Bismuth, MD¹, Joseph J. Naoum, MD¹, Imran T. Mohiuddin, MD¹, Mark G. Davies, MD, PhD¹, Eric K. Peden, MD¹, Michael J. Reardon, MD¹, Alan B. Lumsden, MD¹.
¹Department of Cardiovascular Surgery, Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, Houston, TX, USA, ²The Methodist Hospital Research Institute, The Methodist Hospital, Houston, TX, USA.

OBJECTIVES:TEVAR is limited by inadequate proximal and distal landing zones. Debranching or Hybrid TEVAR has emerged as an important modality to expand landing zones and facilitate TEVAR. We report a single-center experience with hybrid TEVAR.
METHODS: We retrospectively reviewed all the patients with thoracic aortic disease who received a TEVAR between February 2005 and December 2007
RESULTS: 36 patients underwent a hybrid procedure (mean age 67 ± 12 yrs; 21 men). Fourteen (39%) of cases were symptomatic on presentation and 14(39%) patients had had prior aortic surgery. 26(72%) underwent debranching of the Arch, 7(20%) of the visceral vessels and 3(8 %) required both. 18(50%) of the procedures were staged and 2(11%) were performed emergently. Of the patients 33(89%) had American Society of Anesthesiologist score of 4 and above. Primary technical success was achieved in all cases. The 30 days mortality was 11%. Morbidity was 77%; respiratory failure developed in 16 (44%) patients, stroke or transient ischemic attack in 5(14%) patients and spinal cord ischemia in 5(14%) patients with 4(9%) patients having persistent paraplegia on discharge. 15(52%) patients were discharged home and 6(21%) required rehabilitation. There was a significant association between debranching of visceral vessels and persistent paraplegia (p=0.009) (Table 1) and between non-staged hybrid procedure and gastrointestinal complications (p=0.008) (Table 2)
CONCLUSIONS:
Hybrid procedures can successfully extend the range of patients suitable for a subsequent TEVAR. However mortality and morbidity remains high as the procedure is offered to sicker patients, which suggests that further studies, to identify the patients best suited for hybrid TEVAR, are required.
Table 1: Number (%) by Debranching Type


	Arch (n=26)	Visceral (n=7)	Both (n=3)	P-value
Respiratory Failure	9 (35)	3 (43)	0 (0)	0.53
Renal failure	3 (12)	1 (14)	0 (0)	1.0
GI	3 (12)	3 (43)	0 (0)	0.09
SCI	2 (8)	3 (43)	0 (0)	0.09
Paraplegia	0 (0)	3 (43)	0 (0)	0.009
CVA TIA	4 (15)	0 (0)	1 (33)	0.26
Death	6 (23)	2 (30)	1 (33)	NS*

	Hybrid non-staged	Hybrid staged	P value
Respiratory Failure	7(39)	9(50)	0.7
Renal failure	2(11)	2(11)	1.0
GI	7(39)	0(0)	0.008
SCI	3(17)	2(11)	1.0
Paraplegia	2(12)	1(6)	0.6
CVA/TIA	3(17)	2(11)	1.0
Death	6(33)	3(17)	0.4

* NS= non-specific
Table2: Number (%) by Staged

Hybrid non-staged Hybrid staged P value

Respiratory Failure 7(39) 9(50) 0.7

Renal failure 2(11) 2(11) 1.0

GI 7(39) 0(0) 0.008

SCI 3(17) 2(11) 1.0

Paraplegia 2(12) 1(6) 0.6

CVA/TIA 3(17) 2(11) 1.0

Death 6(33) 3(17) 0.4

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