1. Classifications and treatment options for thoracoabdominal aortic aneurysms (TAAAs) are discussed, including open repair, endovascular repair (TEVAR), and hybrid procedures combining open and endovascular techniques. 2. Complications of open TAAA repair can include ischemia-induced injury to organs and spinal cord paralysis, while endovascular options may reduce blood loss, stress response, and recovery time. 3. Hybrid procedures involving surgical debranching of visceral arteries combined with TEVAR can benefit high-risk patients and provide alternatives to open repair, with lower reported complications and mortality compared to open surgery.

2. Classifications of TAAA
I II III IV V

3. TAA: Open Repair

5. Morbidity of
Thoracoabdominal
Open Resection
Most complications related to
ischemia-induced injury to:
Viscera
Kidneys
Spinal cord

6. Paraplegia
False aneurysms
Re dissection
Paralysis
Stroke
Renal failure
Infection
Complications

7. ENDOVASCULAR
REPAIR
“The New Frontier “

8. Advantages
Minimally invasive
Reduces blood loss (up to 60% less)
Reduced stress response
No aortic cross clamp necessary
30 day survival advantage
Earlier ambulation with less pain
Shorter hospital stay (50%) with less strain
on ICU beds

9. Thoracic Endograft
Recommendations
2cm
Left
subclavian
Celiac 2cm
Thoracic Endograft
TEVAR

10. The Pathology
extents to involve
the Visceral
Branches
PROBLEM ?

11. “Solutions for Endovascular
Repair"
Branched/Fenestrated
TEVAR
CHIPS: Chimney /
Periscope/Sandwich
Debranching / Hybrid

12. CHIPS:
Chimney
Periscope
Sandwich

16. Technical Considerations
Chimneys

17. Periscope Technique

18. Multiple periscopes and chimneys
grafts might be an issue as regards
aneurysm sealing.
The more chimney/periscope
grafts, the more the aortic lumen is
narrowed at the level of the landing
zone(s).This might be problematic in
aortas with a diameter of <16mm,
especially for periscope grafts that
are perfused in a retrograde
manner.
Limitations

19. The Importance of Sizing
Narrow Aorta
Increased radial
force Bridging
stent compression

20. Bail Out Narrow Aorta
PLAN: A
Hybrid
Procedure

21. Bail Out Narrow Aorta
Scallop SMA
Chimney Renal Artery
PLAN: B

22. The Importance of Overlap
Minimum

23. Sandwich Technique

31. The Importance of Sizing
MAD + ½ CHIPS Diameter
24mm +[ (7mm+6mm) ] : 2 = 30.5mm
CHIPS: CHImney, Periscope, Sandwich
15% Oversizing=
Type 1 Endoleak
30% Oversizing=
The Ideal
40% Oversizing=
Infolding

32. Debranching /
Hybrid Repair
KFSH&RC
Experience

33. Selection of Cases
 Inoperable based on high risk
Denied surgery from other Centers
May tolerate laparotomy but not
cross-clamping, the end-organ
ischemia or the extensive aortic
resection

34. How morbid the Aortic
Debranching & Endograft
Placement Is?
Is a long and not at all a minimal
invasive procedure for the
patient and the surgeons.

35. The Procedure:
 Visceral & renal
arteries transposition /
bypass
 Followed by TEVAR
A Combined Approach
require a thorough
analysis and a decision
making process

36. Technical Aspects of the Debranching
Can Be A Challenge!
Renal
Revascularization
–End to end
anastomosis

37. Technical Aspects of the Debranching
Can Be A Challenge!
Celiac
Revascularization
–Retropancreatic
tunnel, may not
be easy!

38. GORE® and designs are trademarks of W. L. Gore & Associates. © 2011 W. L. Gore & Associates, Inc.
The GORE® Hybrid Vascular Graft

39. GORE® and designs are trademarks of W. L. Gore & Associates. © 2011 W. L. Gore & Associates, Inc.
Aortic Debranching
Benefits:
• Reduction in organ ischemic time
• Ease of deployment
• Decrease operative exposure and trauma
to patient
• Easier access to deep aortic branch arteries

40. GORE® and designs are trademarks of W. L. Gore & Associates. © 2011 W. L. Gore & Associates, Inc.
Implantation Steps
There are two ways to implant the GORE® Hybrid Vascular
Graft:
• Standard Technique
• Over the Wire Technique

41. Case 1 : History
A 56-yo gentleman, who had previous h/o
large descending Thoracic aortic aneurysm
s/p TEVAR in 2008.
PMD: Heavy smoker, HTN, severe COPD

42. 2011
Left leg claudication
and severe abdominal
angina (became
cachectic) .
CTA:
– Increase size of
supra celiac aorta
(8.6cm) and
IRAAA(6.6cm).

43. CTA 2011
Supraceliac Aorta 8.6cm IRAAA 6.6cm

44. Occlusion of Celiac artery and severe stenosis of SMA

45. LT CIA & EIA occlusion
Bilateral renal artery stenosis
Atrophic Rt Kidney

47. What To Do Next ?
Branched /
Fenestrated stent
graft.
CHIPS
Hybrid procedure.
Open surgical
repair.

48. Rupture TAAA
Presented to ER c/o severe back pain and
become hypotensive.
Stat C-X Ray: contained ruptured thoracic
aneurysm .

49. Surgery
He was rushed to OR.
Spinal drainage was inserted and pressure
kept below 10 mmHg.
At exploration: He had large supra renal
hematoma extending to the chest and
posterior mediastinum.
The infrarenal portion of his TAAA was not
ruptured

50. Surgical Repair of Infrarenal portion of
TAAA
Left kidney was harvested first for
auto transplant.
Infrarenal aortic clump was applied
and Aorto Bifemoral Bypass was
created.
Aorto-SMA bypass was done from the
distal portion of the ABFB graft.

51. Endovascular Repair of Thoracic portion of
TAAA
Two stent grafts were deployed from
the previous thoracic stent graft to
inside the aortobifemoral bypass graft
via the left limb of the ABFB graft.
Auto transplant of the previously
harvested LT Kidney to the right limb
of our aortobifemoral bypass graft .

53. postoperatively
No paraplegia.
Renal profile : Normal.
Abdominal angina resolved.
Tolerated oral diet well.

54. good flow to the kidney patent aorto-SMA bypass graft.
Postoperative CTA

55. Case 2 : History
52-year-old male was referred to us with
enlarging thoracoabdominal aortic aneurysm
Type3 (extending from the midthoracic aorta to
the aortic bifurcations)
C/O: severe leg claudication and back pain.
PMH:
– Severe COPD.
– stroke with mild right hemiparesis and slurred
speech.
– hypertension, diabetes and epilepsy .

56. Work up
CTA:
– Large Type III TAAA (6.5cm)
.
– Thrombosis of IR portion of
TAAA and both CIA.
– Stenosis of celiac artery,
Patent SMA.
– Left renal artery occlusion
with atrophic left kidney.
– Right renal stenosis
– Normal creatinine level.

57. CTA
Distal Thoracic Aorta
Supraceliac Aorta

58. CTA
RT Renal Artery stenosis
Atrophic LT Kidney
Thrombosis of IRAAA

59. CTA

60. CTA

61. What To Do Next ?
Branched
/Fenestrated stent
graft (? access).
CHIPS(? access).
Hybrid procedure.
Open surgical
repair.

62. Surgical repair of Infrarenal portion of
TAAA
Spinal drainage was inserted and pressure
kept below 10 mmHg.
Bifurcated graft was anastamose to the
thrombosed AAA without aortic clamping
for ABFB.
Second bifurcated graft was sutured to the
distal ABFB graft and Rt renal artery, SMA
and celiac artery
Open thrombectomy of the aorta.

63. Endovascular Repair of Thoracic portion of
TAAA
Two stent grafts were deployed
from distal aorta to inside the
ABFB graft via the Lt limb of the
graft
Completion angiogram revealed
no Endoleak with good flow to Rt
kidney, SMA and Celiac artery

65. Aortobifemoral Bypass Graft
Aorto-Renal & Aorto-Celiac/SMA Bypass

66. Anastomosis of the graft to the Celiac Artery

67. Anastomosis of the graft to SMA & RT Renal artery

72. Postoperatively
Kidney function deteriorated
then normalized.
No stroke.
No paraplegia.

73. Case 3 :
75 y/o male, severe back pain
type 5 TAAA,
on steroids S/P kidney transplant.
kidney
transplant

82. 3-D Reconstruction
Post Aneurysm Exclusion
No Endoleak

83. Complications
• Paraplegia
• Renal Failure
• Respiratory Failure
• Re-intervention

84. Hybrid Procedure
A more tolerable procedure with
less morbidity affords high risk
patients alternative to open repair.
Complications and mortaliy
are lower.
Neuro events significantly less.

85. Conclusions
Rapid improvement in Endograft
technology over last 10 years has
expanded the indications for
Endoluminal grafting
Hybrid repair (debranching) and CHIPS
techniques are various options available
with low risk and off the shelf hardware
The choice of a preferred technique
depends on Experience, availability and
Urgency
The “fit” young patient with unfavorable
anatomy is still controversial