Infrarenal aortic repair with or without false lumen intentional placement of endografts for hybrid management of complex aortic dissection.

OBJECTIVE: Aortic dissection (AD) often involves the infrarenal aorta. We review our experience with open infrarenal aortic repair with or without false lumen intentional placement (FLIP) of endografts in the proximal dissected aorta as part of a hybrid strategy to treat complex AD.

METHODS: A prospectively maintained database of patients undergoing intervention for AD was reviewed. Data regarding diagnosis, imaging features, nature of the infrarenal repair (one- vs two-stage procedure), endoleaks, need for additional interventions, morbidity, and mortality were collected.

RESULTS: Between 2006 and 2017, there were 16 patients with AD with thoracoabdominal aortic aneurysm (TAAA), malperfusion, or both who underwent open infrarenal aortic repair or replacement combined with endovascular repair in a single- or multiple-stage procedure. Fifteen patients had a chronic AD and one patient had an acute AD. The most common indication for intervention was absolute size or rapid growth of the abdominal, thoracic, or thoracoabdominal aortic aneurysm (65%). In four patients with AD, the infrarenal replacement surgical graft was used as a common distal seal zone, allowing FLIP of an endograft to treat the proximal AD. Ten (62%) cases were done in two or more stages. Three patients had infrarenal aortic replacement with debranching only. In two of these patients, the proximal dissected aorta has remained stable without aneurysmal degeneration. One patient died as a result of rupture of his aneurysm while awaiting the second stage (perioperative mortality, 6%). Patients were observed from 1 month to 7 years. One patient had a stable type II endoleak, and one patient required subsequent replacement of ascending aortic arch for aneurysmal disease. One patient died of unrelated causes on follow-up.

CONCLUSIONS: Hybrid infrarenal aortic repair for treatment of complex AD can be performed with low morbidity and mortality and excellent medium-term results. This strategy can resolve malperfusion while simultaneously creating a landing zone using the false lumen as the conduit for the stent graft (FLIP) in selected patients. The FLIP technique allows full expansion of the endograft, potential preservation of lumbar and intercostal artery flow, and exclusion of the weaker false lumen while, in some cases, decompressing and thus stabilizing the proximal dissected aorta.