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Central Surgical Association

49th Annual Meeting

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Hybrid Endovascular Approach to Type A Aortic Dissection Repair Improves 30-Day Survival
Alex R. Dalal1, Shernaz S. Dossabhoy2, Elbert E. Heng1, Matthew Leipzig1, Spencer A. Bonham1, Jason T. Lee2, *Y. Joseph Woo1, *A C. Watkins1
1Cardiothoracic Surgery , Stanford University, Palo Alto, California, United States, 2Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California, United States

Objective: Treatment approach to type A aortic dissection with malperfusion is controversial between immediate open aortic repair versus upfront endovascular treatment of malperfusion. The optimal timing and approach for type A aortic dissection with malperfusion remains unclear.

Methods: All type A aortic dissection operative repairs were performed in a traditional operating room prior to 2019 when our institution transitioned to a fixed-fluoroscopy, hybrid operating room. From January 2017 to July 2021, 301 consecutive type A repairs were evaluated at our institution. Propensity score matching was used to control for baseline patient characteristics to compare perioperative, 30-day, and long-term outcomes between traditional versus hybrid operating room approaches.

Results: There were 144 patients in the traditional group and 157 in the hybrid group. In the hybrid group, 31% (48/157) underwent intraoperative angiograms, and of those, 50% (24/48) received at least one endovascular intervention at the time of open aortic repair (41.7% SMA, 12.5% renal, 8.3% iliac, 37.5% TEVAR, 20.8% other location). Following propensity matching, 122 patients remained in each the traditional and hybrid groups. Thirty-day mortality was significantly lower in the hybrid cohort at 4.1% (5/122) as compared to the traditional cohort at 11.4% (14/122) (p=0.03, Figure). Permanent stroke at 30-days was similarly lower in the hybrid vs. traditional group (3.3% vs. 12%, p=0.01). There were no significant differences in perioperative 30-day outcomes between the hybrid and traditional groups with regard to paralysis (2.5% vs. 2.5%, p>0.99), new hemodialysis (11% vs. 9.8%, p=0.83), fasciotomy (5.7% vs. 2.5%, p=0.20, and exploratory laparotomy (3.3% vs. 1.6%, p=0.68, Table). ICU and hospital length of stay were also similar between the hybrid and traditional groups 4 [IQR: 3 – 7] days vs. 4 [IQR: 3-8] days (p=0.91) and 11 [IQR:7-17] days vs. 9 [IQR: 7-17] days (p=0.31), respectively. Additionally, the rate of aortic re-interventions was similar between the two cohorts at 26% in hybrid vs. 21% in traditional cohort (p=0.305) over mean follow-up of 1.16[IQR: 0.66-1.79] years and 2.43 [IQR: 0.74-3.65] years, respectively. At 1-year, there was a trend towards higher survival in the hybrid group at 92.6% vs. 85.2% in traditional, though this did not reach statistical significance (p=0.06).

Conclusions: The hybrid operating room approach to type A aortic dissection provides the ability to immediately assess distal branch malperfusion and potentially perform endovascular interventions at the time of open aortic repair. Treating life-threatening malperfusion concomitantly with definitive open aortic repair is associated with significantly higher 30-day survival and significantly lower 30-day permanent stroke when compared to a stepwise repair approach in a traditional operating room.

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