Two stage hybrid endovascular and open surgical repair for extending the distal landing zone of a thoracoabdominal aortic aneurysm

Introduction: Open thoracoabdominal aortic aneurysm (TAAA) repair carries a risk of significant morbidity and mortality. Thoracic endovascular aortic repair is an alternative, less invasive approach with lower morbidity and mortality and reduced paralysis rates are reported.

Method: A 67-year-old women, who had undergone surgical replacement of the ascending aorta 10 years back, presented with a TAAA type Crawford extents I with a maximal diameter of 6.0cm ending shortly above the celiac artery.

Since a safe distal landing zone was not guaranteed without the risk of an endoleak type I, it was decided to extent the distal landing zone with an open surgical approach. A lateral thoractomy was performed and under femoro-femoral cardio-pulmonary bypass a short segment (4cm) of Dacron graft (28mm) was interposed above the celiac artery. A second stage thoracic endovascular repair of the descending aorta with two endografts (Medronic Captiva 46/200 proximal and 40/160 distal) was performed seven days later in a fully-equipped endovascular room with a high-quality, stationary x-ray system.

Result: The aneurysm was successfully occluded without an endoleak. The patient made a complete recovery with no neurological deficit.

Conclusion: To ensure an adequate and safe distal landing zone in TAAA a combined endovascular and surgical procedure with extending the distal landing zone can be performed with very short operation time and very low morbidity and mortality.

Short follow-up in our initial patient suggests that this approach is to be considered a feasible and effective surgical technique, but a larger number of cases and a longer follow-up are required before expanding current indications for this approach.