Surgeons urged to explore hybrid arch repair frontier

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Joseph Coselli of the Baylor College of Medicine, Texas, USA, has called on the vascular field to explore hybrid endovascular techniques to repair diseased aorta with just one procedure.

“This business of staging the procedures has an ingrained risk in the interval between the two procedures,” said Coselli. “This can be anywhere from zero to 25%. We still have this to deal with. So the idea of treating everything at once is very appealing.


“The first early success using the arch replacement with debranching was published in 1998 in the Journal of Endovascular Surgery. where a failed arch repair was followed by debranching and stentgrafting.


“The concept became immediately and widely adopted. Potential benefits included a reduction in the use of cardiopulmonary bypass, eliminating hypothermic circulatory arrest and cardiac ischaemia, the prevention of late complications, and, being done in one procedure, avoiding the period of time between the two procedures.”


Coselli described techniques for treating the different zones of the aortic arch, the innovative technical variations that are being pursued, and the challenges inherent in each procedure.


He presented unpublished data from a series of 151 thoracic endovascular repairs, of which 61 were hybrid procedures. Within this hybrid group, 14 had chronic aortic dissection. Coselli reported a mortality rate from this group of 6.5%, and a paraplegia rate of 1.6%.


Coselli compared aortic arch repair to the Toyota Prius, the first mass-produced “hybrid” car – powered partially by petrol and partially by electricity – that, after a sceptical reception upon its launch in 1997, has come to dominate the new market for fuel-efficient vehicles.


The treatment options currently available demand creative use, he said. “Disease doesn’t follow these simple guidelines of 2cm above and 2cm below, which are the on-label use. Off-label uses are necessary for our armamentarium.


“There’s no question that when we get the really adaptable, off-the-shelf branch grafts we all would like to see that much of what we’re talking about will be rendered moot.”


Coselli was addressing delegates at the International Congress on Endovascular Interventions in Scottsdale, USA, in February 2009.

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