Aortic Arch Repair With Single Stage Hybrid Antegrade Thoracic Endovascular Aortic Repair Versus Two-stage Hybrid Repair
Mahmoud Alhussaini1, Seyed Hossein Aalaei-Andabili1, Salvatore Scali2, Robert J. Feezor2, Tomas Martin3, Philip Hess4, Charles Klodell1, Teng C. Lee1, George Arnaoutakis1, Thomas M. Beaver1.
1Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, FL, USA, 2Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA, 3Cardiovascular surgical services at Florida Hospital, Orlando, FL, USA, 4Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Indiana University, Indianapolis, IN, USA.
OBJECTIVE: We compared outcomes of single stage hybrid arch replacement using antegrade Thoracic Endovascular Aortic Repair (TEVAR) (“Frozen Elephant Trunk”) versus two-stage hybrid repair with arch debranching/elephant trunk in the first stage and second stage TEVAR.
METHODS: University single center retrospective review (2003-2016) of n=118 patients undergoing hybrid repair of the aortic arch with TEVAR: n=48 single stage versus n=70 two-stage. Patients’ demographics, intraoperative and postoperative outcomes were reviewed.
RESULTS: 48 patients including 31 (64.6%) male and 17 (35.4%) female with mean±SD age of 64±11 underwent single stage procedure and 70 patients including 42 (60%) male and 28 (40%) female with mean±SD of 65.67±13.3 underwent two-stage procedure (age p=0.46). More Emergent procedures were performed in 23/48 (47.9%) single stage patients vs. 8/70 (11.43%) two-stage patients (P<0.001). The mean Cardiopulmonary bypass time for single stage vs. two-stage is 267.6±80 vs. 212.2±64.9 (p<0.001). Fifty-five (84.62%) first stage patients completed the second stage. Respectively between single and two-stage groups there was no difference in stroke, 6.25% (N=3/48) vs. 14.28% (N=10/70) (P=0.23) or spinal cord ischemia 4.16% (N=2/48) vs. 5.7% (N=4/70) (p=1.0). There was no difference in 30-day mortality: single stage 9/48(18.75%) versus the combined 30-day mortality of two-stage 16.24% (5/70 (7.14%) for first stage and 5/55 (9.1%) for second stage) (p=0.61). Median follow up time was 31 months (range: 1-127). Overall survival including 30-day mortality at 6, 12 and 24 months was: single stage 74%, 72% and 72% versus two-stage completion: 83%, 77% and 39% versus single stage only: 59%, 59% and 41% (Figure-1).
CONCLUSIONS: Both single stage and two-stage hybrid arch replacements are effective approaches for treating complex aortic arch pathology. Early mortality and neurological outcomes are not inferior in single stage group versus a two-stage approach. Furthermore, in this series single stage hybrid patients had higher survival at 2-years.
Figure-1. Mid-term survival rates in single-stage patients , both first and second stage procedures, and those who had first stage procedure only.
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