Combined Endovascular and Open Revascularization

General Review Combined Endovascular and Open Revascularization David Paul Slovut, and Timothy M. Sullivan, Salem and Boston, Massachusetts, and Minneapolis, Minnesota

The last decade has borne witness to a transformation in the care of patients with vascular disease. There has been a rapid transition towards minimally invasive techniques as interventionalists obtain increasingly advanced catheter-based skills and access to newer and more sophisticated devices. Patients who are not candidates for completely percutaneous revascularization, or those felt to be at prohibitive risk for traditional surgical reconstruction, may benefit from hybrid therapy, a combination of open surgery and endovascular repair that offers patients the opportunity for complete revascularization with decreased morbidity and mortality. This review examines applications of hybrid procedures for treating patients with disabling claudication and limb-threatening ischemia, aortic arch disease, thoracoabdominal aneurysms, extracranial carotid disease, and coronary artery disease.

INTRODUCTION The last decade has borne witness to a transformation in the care of patients with vascular disease. There has been a rapid transition toward minimally invasive techniques as interventionalists obtain increasingly advanced catheter-based skills and access to newer and more sophisticated devices. However, a significant number of patients are not candidates for completely percutaneous endovascular revascularization due to complex anatomy or suboptimal lesion location. These patients may benefit from hybrid therapy, a combination of open surgery and endovascular repair that achieves complete revascularization in patients whose comorbidities would otherwise preclude them from traditional open surgical repair.

North Shore Medical Center, Salem, and Massachusetts General Hospital, Boston, MA. Minneapolis Heart Institute, Minneapolis, MN. Correspondence to: David Paul Slovut, MD, PhD, North Shore Medical Center, 81 Highland Avenue, Salem, MA 01970, USA, E-mail: david. [email protected] Ann Vasc Surg 2009; 23: 414-424 DOI: 10.1016/j.avsg.2008.12.001 Ó Annals of Vascular Surgery Inc.

414

This review examines applications of hybrid procedures for treating patients with disabling claudication and limb-threatening ischemia, aortic arch disease, thoracoabdominal aneurysms, extracranial carotid disease, and coronary artery disease.

DISABLING CLAUDICATION AND CRITICAL LIMB ISCHEMIA Critical limb ischemia (CLI), defined as >2 weeks of rest pain, ulcers, or tissue loss attributed to arterial occlusive disease, affects approximately 500e1,000 new patients per million persons per year. The highest rates are found among older individuals, smokers, and diabetics. Its cost, negative impact on quality of life, and poor prognosis as far as limb salvage and survival have made it an extremely important issue.1 Revascularization to reestablish continuous inline flow to the pedal arch represents the preferred treatment to achieve relief of ischemic pain or wound healing.1 Surgical revascularization is warranted for patients with complex lesions not amenable to catheter-based intervention and for younger patients with prolonged life expectancy, who require a more durable revascularization.

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Aortoiliac disease may be treated with anatomic or extra-anatomic bypass (e.g., aortobifemoral, axillobifemoral, or femorofemoral bypass). Primary patency rates of aortobifemoral and femorofemoral bypass at 5 years are 93% and 70%, respectively. Perioperative mortality rates are approximately 3.5%.1 Bypass for infrainguinal occlusive disease is associated with limb salvage rates >80% and mortality rates of 0.97e2.0%.2-4 In the past decade, angioplasty has supplanted surgery as first-line therapy for many patients with CLI.5e10 Endovascular revascularization is appealing as it is minimally invasive and associated with low morbidity and mortality, reduced hospital costs, and decreased length of hospitalization.11 Despite the superior durability of surgical revascularization compared with angioplasty and stenting,12 there has been an 850% increase in utilization of iliac artery angioplasty and stenting and a decrease of 15% in aortobifemoral bypass from 1996e2000.13 An increasing number of patients with limbthreatening ischemia undergo a combination of endovascular and open surgery to achieve complete revascularization with a less extensive operative procedure, shorter duration of operation, and decreased risk of perioperative complications.7,14,15 The endovascular and open portion of the procedure may be performed simultaneously or sequentially. Prior to the advent of modern endovascular operating suites, which have the capabilities of a traditional operating room and high-quality fluoroscopy, procedures were often performed sequentially as imaging in the radiology suite was superior to the imaging in the operating room using a portable C-arm. Now, many hospitals contain operating rooms equipped with state-of-the-art digital fluoroscopy systems that include large image intensifiers as well as software for road-mapping and quantitative analysis. In a hybrid procedure, the endovascular portion may consist of inflow,16-18 outflow,18 a combination of inflow and outflow,19 or revision of a bypass graft.20 Hybrid revascularization is associated with high rates of technical success, patency, and limb salvage (Table I). Endovascular Repair for Inflow The use of an endovascular inflow procedured whether of the aortoiliac segment16,21-23 or the SFA17dconfers long-term patency to the downstream bypass graft. In one of the largest series to date, 125 patients underwent hybrid therapy for de novo arterial reconstruction or revision of a bypass graft.19 Overall, the perioperative mortality was <1% and

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morbidity was 15.4%. Primary patency was 39.6%, assisted primary patency 65.1%, and secondary patency 73.5% over a mean follow-up of 27.6 months. Other investigators have reported excellent limb-salvage rates using hybrid therapy.14,16,18 Ipsilateral greater saphenous vein remains the preferred conduit for infrainguinal bypass. However, with increasing frequency, patients who require distal bypass have insufficient or inadequate vein owing to prior vein stripping or use for coronary artery or peripheral bypass grafting. Alternative vein conduitdincluding lesser saphenous vein, basilic vein, cephalic vein, or composite grafts comprised of autogenous vein or segments of prosthetic material attached to veindcan be used with acceptable patency rates24-27 but often does not provide adequate length for bypasses requiring origin on the common or profunda femoral artery. Infrageniculate prosthetic bypass and autogenous composite grafts provide inferior results.16,27 Endovascular treatment of inflow lesions decreases the length of vein required for complete revascularization without altering long-term outcome. In one series of diabetic patients with lower extremity gangrene, primary and secondary patency rates at 2year follow-up were similar for patients with long bypass grafts originating from the groin, short bypass grafts originating from the popliteal artery, and combined superficial femoral artery (SFA) angioplasty/popliteal bypass grafts.17 Endovascular repair of the SFA may be performed percutaneously using the crossover technique from the contralateral common femoral artery, via cutdown over the ipsilateral common femoral artery, or retrograde via the popliteal artery.

Surgery for Inflow The common femoral artery may be reconstructed using an interposition graft or by performing an endarterectomy and patch angioplasty.21,22,28 It is also sometimes easier to perform femoral endarterectomy and then puncture through the patch angioplasty to perform iliac, SFA, and/or tibial angioplasty. In a series by Kang et al.,29 65 limbs in 58 patients were treated with femoral endarterectomy. Thirty-seven cases (57%) were performed as hybrid procedures where a concomitant endovascular procedure was performed, including both iliac and SFA intervention. Hemodynamic success was achieved in 95% of cases, and there was no perioperative mortality. Primary patency rates at 1 and 5 years were 93% and 91%, respectively; assisted primary patency was 100% at both time points.

Advances in operator skill and improvements in equipment such as reentry devices have increased the percentage of CLI patients whose anatomy is suitable for endovascular therapy from <50% to as high as 84%.5,7,9 For example, subintimal angioplasty has emerged as an effective method for recanalizing long-segment occlusions and is associated with limb-salvage rates comparable to those achieved with bypass.30 Technical success rates are high, but patients often require placement of a stent, which in infrainguinal arteries has been associated with early treatment failure.30,31 One of the main limitations of subintimal angioplasty is failure to reenter the true lumen after subintimal crossing of the occlusion.32 Reentry devices such as the Pioneer catheter (Volcano Therapeutics, Rancho Cordova, CA) improve the ability of operators to reenter the true lumen.32 Postoperative duplex surveillance is essential for maintaining long-term patency of hybrid arterial reconstructions.

56 67 (20)

58

AORTIC ARCH DISEASE

NR, not reported; 10, primary patency; 20, secondary patency.

81 92 (20) 97 100 100 2005 2007 2007 Miyahara et al.16 Cotroneo et al.18 Schanzer et al.23

35 47 23

2001 2002 2003 Timaran et al.89 Nelson et al.21 Dougherty et al.19

45 34 73 (A) 52 (B)

97 100 93 88

84

71 88 (20) 79 (2 years)

65

68

98 NR 90 (5 years) NR 91 (5 years) 96 (A) 85 (B) Group A stenosis <5 cm Group B stenosis >5 cm NR Infrainguinal graft patency NR NR Group A ¼ bypass Group B ¼ revision of previous reconstruction 97 (5 years) NR 70 (5 years) 85 80 97 77 95 76 88 (2 ) 100 87 79 79 100 NR 100 (A) 62 (B) 96 (A) 46 (B) 85 (A) 31 (B) 1989 1989 1989 1996 1999 2001 Spoelstra et al.84 Weber and Kiss85 Brewster et al.86 Perler and Williams87 Melliere et al.14 Aburahma et al.88

79 78 75 26 64 41

1-year 10 patency (%) Endo success (%) Year

n

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Authors

Table I. Results of hybrid procedures for lower limb revascularization

3-year 10 patency (%)

5-year 10 patency (%)

Limb salvage (%)

Comment

416 Slovut and Sullivan

Traditional operative repair of aortic arch aneurysms and dissection requires hypothermic circulatory arrest, extracorporeal circulation, and selective cerebral perfusion. Even in high-volume centers, open repair is associated with renal failure in 0e17%, paraplegia in 2e16%, and 30-day mortality of 5e 19% of cases.33 Reoperative arch repair, particularly for emergent indications, is associated with even greater rates of morbidity and mortality.34 The introduction of endovascular stent grafts has allowed patients who are considered at high risk for traditional open surgery to be repaired using less invasive methods. Hybrid arch repair requires ‘‘debranching’’ and reimplantation of the supraaortic vessels to increase the length of the proximal landing zone and achieve an adequate seal. Surgical transposition may be extra-anatomic or intrathoracic. During intrathoracic procedures, the distal segment of the aorta may be banded to improve endograft fixation.35 In most patients, covering the left subclavian artery does not produce arm or hand claudication. However, left carotid to subclavian bypass may decrease the risk of paraplegia by protecting collateral blood supply to the spinal cord artery.36,37 Left carotid to subclavian bypass should also be performed for patients who have had a left internal mammary artery graft or have an isolated left vertebral artery (Fig. 1). Endografts may be delivered via common femoral artery cutdown or for patients with small-caliber

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external iliac artery (diameter <6 mm), via iliac conduit. The usefulness of iliac conduits in patients with unfavorable iliac anatomy cannot be overemphasized. In a series of 312 patients having endovascular aortic aneurysm repair, 22 required placement of a conduit via a retroperitoneal flank incision.38 The conduit consisted of an 8 or 10 mm Dacron graft anastomosed to the common iliac artery. Not surprisingly, operative time, blood loss, time in the intensive care unit, and hospital length of stay were higher in the group requiring a conduit, especially when the procedure was ‘‘unplanned.’’ Cardiac, renal, and pulmonary complications were similar when compared to those patients who did not require a conduit. Newer-generation thoracic stent grafts are more flexible, can be delivered more easily through tortuous iliac arteries, and conform better to markedly angled aortic arch. Adenosine may be used to transiently slow or stop the heart to facilitate precise graft positioning and deployment. Manipulation of the aortic arch during stent-graft implantation may lead to stroke. In the pivotal study of the TAG endoprosthesis (Gore, Flagstaff, AZ), stroke was reported as a complication in 4% of patients.39 Four of the five patients who suffered stroke had carotidesubclavian bypass due to proximal aneurysmal disease. Of 28 patients who underwent carotidesubclavian bypass, 14% suffered stroke compared with 1% who did not require aortic debranching ( p < 0.001). Of note, three of five strokes affected both the anterior and posterior cerebral distributions, a finding which suggests that atheromatous embolization was the etiology of stroke in these patients. The Heidelberg group adopted the following criteria for performing hybrid arch reconstructions: age >70 years, high-risk patients with a contraindication for open surgery, emergency cases and redo surgery, healthy ascending aorta with adequate diameter to serve as donor site for great vessel reimplantation.40 Preprocedure imaging was performed using computed axial tomography angiography with multiplanar reconstruction. Perioperative mortality in 25 patients who underwent hybrid arch repair was 20%. The cause of death included stent perforation of the aorta, embolic stroke, and cardiac failure.40 Outcomes for hybrid arch reconstructions from several centers are summarized in Table II. Overall technical success is 86e100%, with 30-day stroke rates of up to 20% and mortality of 0e13%. The relationship between the proximal edge of the endograft and the supra-aortic vessels correlates with treatment success and patient outcome. Ishimaru et al.41 proposed a classification system

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Fig. 1. A False aneurysm of the proximal descending thoracic aorta 20 years after patch angioplasty of aortic coarctation. Left subclavian artery originates from aneurysm. Left vertebral artery arises as a separate branch from the aortic arch. b Debranching of the arch to facilitate endovascular aneurysm repair. Left subclavian artery is transposed onto left common carotid artery, and left vertebral is anastomosed to the transposed left subclavian. c Following endovascular repair. At 4-year follow-up, the aneurysm had completely resolved and the transposed vessels remained patent.

418 Slovut and Sullivan

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Table II. Outcomes for hybrid aortic arch procedures Year

n

Technical success (%)

Type I or III endoleak (%)

Paraplegia or CVA (%)

30-day mortality

Schumacher et al. Bergeron et al.44 Greenberg et al.51 Zhou et al.46 Caronno et al.91 Saleh and Inglese35 Szeto et al.43

2003 2005 2005 2006 2006 2006 2007

8 29 22 16 10 15 8

100 96.3 100 100 100 100 100

0 0 4.5 NR 0 0 0

0 7.7 13.6 0 20 0 25

12.5 7.7 0 6.2 10 0 12.5

Melissano et al.45

2007

64

85.9

12.5

6.2

6.3

Baraki et al.49 Chan et al.92

2007 2008

39 16

NR 0

12.8 18.7

12.8 0

Authors 90

100 100

Comment

Elephant trunk 2 late endoleaks 2 perioperative strokes resolved by discharge 9/10 endoleaks resolved spontaneously Elephant trunk

NR, not reported.

for proximal landing zones: zone 0, overstenting of all supra-aortic vessels; zone 1, overstenting of left common carotid and left subclavian arteries; zone 2, overstenting of the left subclavian artery; zone 4, stenting distal to the left subclavian artery. Endoleak rates are higher when the endograft is positioned proximal to the left subclavian artery.42 In one series examining outcomes in 37 patients treated with the Talent device (Medtronic, Minneapolis, MN), the endoleak rate was 100% (3/3 patients) when the graft was placed proximal to the left common carotid artery and 0e11% when the graft was placed beyond the left common carotid artery.42 In contrast, other investigators have successfully treated aneurysms and dissections involving zone 0.43-46 Traditional therapy for aneurysms involving the ascending aorta, the arch, and descending thoracic aorta includes open replacement of the ascending aorta and arch with an ‘‘elephant trunk’’ extension of the arch graft into the descending aorta. The elephant trunk is extended to the desired level in a second operation performed via lateral thoracotomy. Mortality for the first stage is approximately 10%, while mortality for the second stage is 7%.47,48 Some patients succumb to aneurysm rupture while awaiting the second procedure.47 Hybrid reconstruction enables the entire repair to be completed in a single procedure49 or as staged procedures with standard open arch repair followed by staged endovascular stent grafting of the descending thoracic aorta.50 Greenberg and colleagues51 described their experience in 22 patients who required ‘‘elephant trunk’’ and endovascular repair. Technical success was achieved in 100%; mortality rates at 1, 12, and 24 months were 4.5%, 15.8%, and 15.8%, respectively.

TREATMENT OF THORACOABDOMINAL AORTIC ANEURYSMS Open repair of thoracoabdominal aneurysms (TAAA) is associated with spinal cord ischemia (18%), renal failure (18%), dialysis (9%), and a 30-day mortality rate of 8%52. Poor functional outcomes following open are TAAA repair are common; at one-year follow-up 47.6% of patients were deceased, discharged to a long-term care facility, or non-ambulatory53. Combined open and endovascular repair of TAAA has been proposed as an alternative to conventional open repair. Quinones-Baldrich and colleagues54 described the first hybrid TAAA repair, which was performed on a 62-year old man with a type IV TAAA and large aneurysms at the origin of each visceral vessel who had twice undergone repair of ruptured abdominal aortic aneurysm. They performed open extraanatomic bypass of the renal arteries, superior mesenteric artery, and celiac artery followed by stent-graft repair of the aorta. At 6-month follow-up, all grafts were widely patent and no endoleaks were present.54 Results of several series of visceral hybrid TAAA repairs are presented in Table III. Creation of an adequate distal landing zone for hybrid TAAA repair requires bypass of mesenteric and/or renal arteries. Bypasses can originate from the supraceliac aorta, infrarenal aorta, common iliac artery, or external iliac artery. Once perfusion has been reinstituted, the proximal visceral arteries are ligated to reduce the chance of type II endoleak. Laparoscopically assisted or totally laparoscopic debranching may be performed as an alternative to open surgery.55 Use of custom Dacron grafts provides inflow via a single anastomosis, which simplifies debranching and permits the thoracoabdominal reconstruction to be completed in one procedure (Fig. 2).56

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Table III. Outcomes for hybrid thoracoabdominal procedures Type I or III endoleak (%)

Paraplegia or CVA (%)

30-day mortality

31 0 0

23 13 0

Authors

Year

n

Technical success (%)

Resch et al.93 Black et al.61 Zhou et al.46

2006 2006 2006

13 29 15

100 90 100

23 13 NR

Gawenda et al.94 Donas et al.95 Chiesa et al.96

2007 2007 2007

6 8 13

100 100 76.9

None NR 0

Melissano et al.45 Bockler et al.33

2007 2008

14 28

100 89

0 8

0 0 7.7

0 12.5 23

7.1 11

28.6 14.3

Comment

Renal graft thrombosis 6.4% No paraplegia Mortality includes 1 death at 35 days

NR ¼ not reported.

For TAAA reconstructions, predictors of paraplegia and paralysis include total aortic clamp time, extent of aorta repaired, patient age, aortic rupture, and history of renal dysfunction.52 Using an endograft to exclude a TAAA obviates the need for aortic cross-clamping but still carries the risk of spinal cord ischemia as the graft may occlude crucial spinal cord collaterals.57 Blood supply to the spinal cord derives from arteries in the spinal canal, intercostal arteries, and subclavian and hypogastric arteries.37,58 Patients at high risk for paraplegiad those with prior aneurysm repair or requiring coverage of long aortic segmentdmay benefit from monitoring of somatosensory evoked potentials, arterial pressure augmentation, and cerebrospinal fluid drainage.59 Routine reimplantation of segmental arteries does not decrease the incidence of spinal cord ischemia.60 Although far less invasive than conventional open repair, hybrid TAAA procedures are associated with significant morbidity and mortality. In one series, major complications included prolonged ventilatory support (34.6%), prolonged inotropic support (15.4%), renal impairment (15.4%), stroke (3.8%), and type I endoleak (25%). The median intensive care unit stay was 4 days, the median hospital stay was 27 days, and the 30-day mortality rate was 13%.61 In another series, the major complication rate was 59%, 30-day mortality was 14.3%, and the overall survival rate at 3 years was 70%.33 Until the long-term results, safety, and durability of hybrid TAAA repair are determined, a reasonable approach is to offer conventional open repair to younger patients and reserve hybrid repair for older, high-risk patients. Purely endovascular TAAA repair is feasible using fenestrated and branched endografts.62-64 Many of these devices are still custom-made and require specialized imaging systems so that accurate

fenestrations can be made precisely. Improper graft rotation at the time of implantation may lead to side branch occlusion.62 Long-term patency of renal and visceral side branches remains unknown. The technology for fenestrated grafts remains in its infancy and is not feasible for all patients.

HYBRID EXTRACRANIAL CAROTID REVASCULARIZATION Management of patients with coexisting severe carotid artery stenosis and coronary artery disease remains both challenging and controversial. A review of 97 published studies following 8,972 staged or synchronous operations showed highest operative mortality (4.6%) when carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) were performed simultaneously, highest rate of myocardial infarction (6.5%) when CEA was performed before CABG, and highest stroke rate (6.3%) when CABG was performed before CEA.65 The event rate for the composite of myocardial infarction, stroke, and death was 10e12%. Carotid artery stenting (CAS) with cerebral embolic protection has emerged as an alternative to CEA for ‘‘high-risk’’ patients.66,67 In the United States, approximately 3.3% of patients with coexisting carotid and coronary disease undergo carotid stenting.68 After adjusting for age, gender, symptomatic status, and comorbidities, patients undergoing CEAeCABG had a 66% increased risk of postoperative stroke compared with patients undergoing CASeCABG. The presence of neurological symptoms substantially increased the risk of postoperative stroke. In-hospital mortality was similar (5.2% vs. 5.4%) for both groups.68 Although relatively uncommon in clinical practice, patients with significant occlusive disease of

420 Slovut and Sullivan

Fig. 2. Endovascular repair of TAAA with debranching of the superior mesenteric artery using a bypass from the right iliac artery.

the proximal common carotid artery and the carotid bifurcation represent a significant clinical challenge. Before the advent of angioplasty and stenting, these patients required either carotidesubclavian transposition or bypass in conjunction with bifurcation endarterectomy. Of 14 consecutive common carotid artery stent procedures performed at the Cleveland Clinic, one was converted to carotidesubclavian transposition following iatrogenic dissection and two other procedures resulted in stroke secondary to internal carotid artery thrombosis.69 In both cases, which were performed in conjunction with redo bifurcation endarterectomies, the common carotid was patent at the time of surgical reexploration and internal carotid thrombectomy. While the carotid stent procedure was not likely implicated, caution is urged when performing these combined procedures. Other investigators have documented the safety and durability of CEA in conjunction with angioplasty and stenting of the left common carotid artery and the innominate artery.70,71 Hybrid Coronary Artery Revascularization CABG remains the optimal therapy for patients with left main and multivessel coronary artery disease.72

Annals of Vascular Surgery

Multivessel percutaneous coronary intervention (PCI) is associated with increased incidence of instent restenosis and repeat revascularization.72 Hybrid coronary revascularization using an internal mammary artery (IMA) graft to the left anterior descending artery (LAD) and PCI of the circumflex and/or right coronary artery has been proposed as a minimally invasive means of achieving complete coronary revascularization in selected patients. The IMA graft confers survival benefit.73,74 The patency of stents in the circumflex and right coronary arteries rivals the patency of saphenous vein bypass grafts. In many centers, LAD revascularization is accomplished using a minimally invasive direct coronary artery bypass (MIDCAB), in which the IMA is harvested via a left anterior minithoracotomy and sutured on the beating heart without cardiopulmonary bypass. At 5 years following MIDCAB to revascularize the LAD, survival was 95.8%, cardiac event-free survival was 80.8%, and freedom from repeat LAD revascularization was 91.6%.75 Robotic manipulation systems improve the ease of IMA harvest.76 Improvements in technology and operative technique have enabled some centers to perform totally endoscopic, robot-assisted, closedchest bypass of the IMA to LAD.76 When the IMA anastomosis is performed ‘‘off-pump,’’ the aorta is not manipulated, which decreases the risk of perioperative stroke.75,77 Results of several series of hybrid coronary revascularization are presented in Table IV. Another example of hybrid coronary revascularization involves performing PCI in conjunction with mitral or aortic valve replacement as an alternative to conventional CABG and valve surgery.78,79 Bypass may be performed prior to, simultaneously, or following PCI. Advantages of a surgeryfirst strategy include a ‘‘protected’’ anterior wall and the ability to evaluate the quality of the IMA bypass during subsequent angiography.80 The PCI may be performed using glycoprotein IIb/IIIa inhibitors and clopidogrel without concern of exacerbating perioperative bleeding. Advantages of a PCI-first approach include assurance that stenting was successful (i.e., no need for multivessel bypass instead of single-vessel CABG). Simultaneous procedures accomplish complete revascularization in one procedure, which is more convenient for the patient. These procedures require an endosuite that serves both as operating theater and interventional suite, as well as close collaboration between cardiothoracic surgeons and interventional cardiologists. Two small prospective case-control series comparing outcomes for simultaneous hybrid revascularization with off-pump CABG (OPCAB) versus

Combined endovascular and open revascularization

0 0 0 0 0 3.4

CONCLUSIONS

0 0 NR, not reported; MI, myocardial infarction.

2008 13 MIDCAB Simultaneous 2008 58 RE-MIDCAB Simultaneous Reicher et al.82 Kiaii et al.79

0 0

NR 1.7

6 20.2 (1.1e40.8)

0 0 6.7 0

35 42 54 57 20 27 70

Simultaneous 2008 15 OPCAB Kon et al.81

0

0

NR

NR NR 0 0 0 0 0 NR 17.5 11.6 (1e23) 25.2±9.5 (0.75e52) 19±10 (12e33) NR 33 (2e70) 0 2.4 0 0 0 0 1.4 0 NR 0 0 0 3.7 0 Surgery 1st Surgery 1st in 64% Varied Surgery 1st PCI 1st in 30% Varied CABG w/in 16 hr of PCI 2000 2001 2002 2002 2005 2006 2007 Wittwer et al.97 Presbitero et al.98 Stahl et al.99 Riess et al.100 Davidavicius et al.83 Katz et al.76 Gilard et al.101

n

MIDCAB MIDCAB RE-MIDCAB MIDCAB RE-MIDCAB RE-MIDCAB Open CABG

Year Authors

421

conventional OPCAB found that patients in the hybrid group had shorter stays in the intensive care unit and hospital, more rapid extubation following revascularization, faster return to work, and higher satisfaction with the procedure.81,82 Despite antiplatelet therapy with aspirin and clopidogrel, bleeding was not increased compared with patients who underwent conventional OPCAB.82 Another strategy for patients with multivessel coronary disease is to perform robotically enhanced MIDCAB (RE-MIDCAB) and provisional PCI of the left circumflex or right coronary artery if the fractional flow reserve (FFR) is <0.80.83 FFR offers a widely accepted means of determining whether a stenosis is significant hemodynamically. In a group of 20 patients treated according to this protocol, there were no deaths, myocardial infarctions, or repeat revascularizations after a mean follow-up of 19 months.83 Hybrid coronary revascularization remains a niche procedure. The anterior exposure required for MIDCAB limits the procedure to patients with isolated LAD or diagonal disease. The learning curve for performing the procedure is steep. Despite development of devices to stabilize the operative field, the LAD anastomosis may be difficult to perform, particularly if the LAD is small, heavily calcified, or intramyocardial. These factors contribute to early graft failure rates as high as 7.7%.75 Robotic devices for harvesting the IMA remain prohibitively expensive.

DaVinci robotic system CABG same day as PCI, 92% of cases ‘‘on pump’’ 1 year follow-up on all patients 15.8% early failure rate 91% graft patency at angiographic follow-up NR NR 1.8 12.7 0 29.6 0 0 7.1 0 1.7 0 0 2.8

NR 2.4 0 1.8 0 0 0

Repeat revasc MI Death (%) (%) (%) Comment Months Repeat Death follow-up revasc (%) MI (%) (%) (mean ± SD, range) Revasc sequence Surgical procedure

Table IV. Outcomes for hybrid coronary artery procedures 30-day outcomes Long-term outcomes

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Hybrid surgical/endovascular procedures may offer patients the opportunity for less invasive complete revascularization at decreased morbidity and mortality, especially those felt to be at prohibitive risk for traditional surgical reconstruction. For those with occlusive disease of the lower extremities, endovascular repair of aortoiliac disease is often combined with open surgical repair of the infrainguinal vessels. For patients with aneurysmal disease, endovascular repair is typically paired with surgical reconstruction of the supra-aortic trunks or mesenteric arteries or with construction of an iliac conduit for access. A thorough knowledge of all potential options will allow the practicing clinician to determine the best revascularization option (endovascular, open surgical, or hybrid) for each individual patient. Hybrid procedures are greatly facilitated by the availability of a dedicated endovascular operating room. REFERENCES 1. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. Inter-Society Consensus for the Management

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2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

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18. Cotroneo AR, Iezzi R, Marano G, Fonio P, Nessi F, Gandini G. Hybrid therapy in patients with complex peripheral multifocal steno-obstructive vascular disease: two-year results. Cardiovasc. Intervent. Radiol 2007;30:355-361. 19. Dougherty MJ, Young LP, Calligaro KD. One hundred twenty-five concomitant endovascular and open procedures for lower extremity arterial disease. J Vasc Surg 2003;37:316-322. 20. Nasr MK, McCarthy RJ, Budd JS, Horrocks M. Infrainguinal bypass graft patency and limb salvage rates in critical limb ischemia: influence of the mode of presentation. Ann Vasc Surg 2003;17:192-197. 21. Nelson PR, Powell RJ, Schermerhorn ML, et al. Early results of external iliac artery stenting combined with common femoral artery endarterectomy. J Vasc Surg 2002;35:1107-1113. 22. Leville CD, Kashyap VS, Clair DG, et al. Endovascular management of iliac artery occlusions: extending treatment to TransAtlantic Inter-Society Consensus class C and D patients. J Vasc Surg 2006;43:32-39. 23. Schanzer A, Owens CD, Conte MS, Belkin M. Superficial femoral artery percutaneous intervention is an effective strategy to optimize inflow for distal origin bypass grafts. J Vasc Surg 2007;45:740-743. 24. Curi MA, Skelly CL, Woo DH, et al. Long-term results of infrageniculate bypass grafting using all-autogenous composite vein. Ann Vasc Surg 2002;16:618-623. 25. Alexander J, Gutierrez C, Katz S. Non-greater saphenous vein grafting for infrageniculate bypass. Am Surg 2002;68:611-614. 26. Gentile AT, Lee RW, Moneta GL, Taylor LM, Edwards JM, Porter JM. Results of bypass to the popliteal and tibial arteries with alternative sources of autogenous vein. J Vasc Surg 1996;23:272-280. 27. Chew DK, Conte MS, Donaldson MC, Whittemore AD, Mannick JA, Belkin M. Autogenous composite vein bypass graft for infrainguinal arterial reconstruction. J Vasc Surg 2001;33:259-264. 28. Kashyap VS, Pavkov ML, Bena JF, et al. The management of severe aortoiliac occlusive disease: endovascular therapy rivals open reconstruction. J Vasc Surg 2008;48:1451-1457. 29. Kang JL, Patel VI, Conrad MF, Lamuraglia GM, Chung TK, Cambria RP. Common femoral artery occlusive disease: contemporary results following surgical endarterectomy. J Vasc Surg 2008;48:872-877. 30. Hynes N, Mahendran B, Manning B, Andrews E, Courtney D, Sultan S. The influence of subintimal angioplasty on level of amputation and limb salvage rates in lower limb critical ischaemia: a 15-year experience. Eur J Vasc Endovasc. Surg 2005;30:291-299. 31. Myers SI, Myers DJ, Ahmend A, Ramakrishnan V. Preliminary results of subintimal angioplasty for limb salvage in lower extremities with severe chronic ischemia and limbthreatening ischemia. J Vasc Surg 2006;44:1239-1246. 32. Jacobs DL, Motaganahalli RL, Cox DE, Wittgen CM, Peterson GJ. True lumen re-entry devices facilitate subintimal angioplasty and stenting of total chronic occlusions: initial report. J Vasc Surg 2006;43:1291-1296. 33. Bockler D, Kotelis D, Geisbusch P, et al. Hybrid procedures for thoracoabdominal aortic aneurysms and chronic aortic dissectionsda single center experience in 28 patients. J Vasc Surg 2008;47:724-732. 34. Luciani GB, Casali G, Faggian G, Mazzucco A. Predicting outcome after reoperative procedures on the aortic root and ascending aorta. Eur J. Cardiothorac. Surg 2000;17:602-607.

Vol. 23, No. 3, May 2009

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