Use of custom Dacron branch grafts for ''hybrid'' aortic debranching during endovascular repair of thoracic and thoracoabdominal aortic aneurysms

Objectives: A significant number of patients with thoracic and thoracoabdominal aortic aneurysms are unsuitable for endovascular repair owing to the absence of graft seal zones. "Hybrid'' techniques, including open aortic debranching procedures, allow creation of proximal and/or distal landing zones and expand the potential applications of endovascular repair. We report our experience with aortic arch and thoracoabdominal debranching using custom fabricated Dacron branch grafts, which greatly simplify aortic debranching by providing inflow via a single anastomosis and incorporate a side arm for introduction of the stent graft. Methods: Between November 14, 2005, and December 18, 2006, a total of 53 thoracic endograft procedures were performed at our institution. Of these, 13 ( 25%) involved either open aortic arch or abdominal debranching to create proximal or distal landing zones for endovascular repair. Patients undergoing arch debranching (n = 7) had aneurysms involving the transverse arch with less than 2 cm of proximal landing zone distal to the innominate artery, necessitating stent graft coverage of both the innominate and left common carotid arteries. Patients undergoing complete abdominal debranching (n = 6) had either thoracoabdominal aortic aneurysms (extent II, n = 1; extent V, n = 3) or visceral button false aneurysms after prior open thoracoabdominal aortic aneurysm repair ( n = 2). In all cases, endovascular aneurysm exclusion was performed at the same operation. Results: Mean patient age was 63611 years ( range 46- 83 years); all patients had significant comorbidities, including prior open aortic surgery in 8 (62%). There were no perioperative ( 30 day) deaths and no permanent neurologic deficits, either cerebrovascular accident or paraparesis/ paraplegia. At a mean follow-up of 7.5 +/- 6.0 months, there has been no late mortality and all debranching bypass grafts remain patent without need for further intervention. Computed tomographic scans demonstrate no type I or III endoleaks, and all aneurysms are thrombosed with stable ( n = 4) or decreasing aortic dimensions ( n = 9). Conclusions: "Hybrid'' aortic debranching using custom fabricated Dacron branch grafts with a single inflow source combined with endovascular aneurysm exclusion appears to be a safe alternative to conventional open repair for thoracoabdominal and arch aneurysms and avoids the need for cardiopulmonary bypass and aortic crossclamping. This technique may be ideally suited to patients with significant comorbidity or prior open aortic surgery. Longer term follow- up is needed to determine the durability of this approach.