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Life-saving surgery for high-risk patients

A new surgical repair of the aorta that obviates the necessity to open the thorax and the abdominal cavity is highly suited to high-risk patients that could not previously be operated due to concomitant diseases or previous surgery.

The new surgical method is aimed at patients with aortic aneurysms that run the risk of rupture and massive inner haemorrhage. Conventional open repair of aortic aneurysms and dissections are complex and associated with a very high risk of mortality.

There is a high risk of rupture once aortic aneurysms have reached 5 cm in size. The operative treatment of thoracoabdominal aortic aneurysms in the chest and abdomen causes great stress to the patient and is associated with a high risk.

Hybrid operative procedures compared to conventional surgery

CT image after thoracoabominal hybrid surgery (Photo: Department of Radiology, DKFZ Heidelberg)
The new surgical method, known as hybrid surgery, includes the insertion of prostheses (stent grafts) into the diseased aorta by way of the femoral artery; conventional surgery requires the opening of the patient’s chest and abdominal cavity. Early results of a long-term study at the Department of Vascular and Endovascular Surgery at the University Hospital of Heidelberg (interim medical director: Prof. Dr. Dittmar Böckler) are encouraging, but far more experience is required to precisely assess the outcome of the new surgical method. The study is the second largest study involving the new hybrid procedure ever done by an individual centre. The findings were recently published in the Journal of Vascular Surgery.

Between January 2001 and July 2007, over 1,700 patients suffering from aortic diseases underwent surgery at the Heidelberg University Hospital, including 78 patients with thoracoabdominal aneurysms. 50 patients were treated with conventional surgery, 28 with the new hybrid procedure. The new method was specifically chosen for patients who would have been put at too a high a risk with conventional surgery, either due to their age or because they had previously undergone aortic surgery, suffered from high blood pressure, coronary heart disease, pulmonary diseases or cardiac or renal insufficiency.

Conventional surgical treatment of thoracoabdominal aortic aneurysms requires the opening of the patient’s chest and abdominal cavity for the diseased part of the vessel to be replaced by a stent. The surgeons have to take great care that the nerves of the spinal marrow are supplied with sufficient amounts of oxygen throughout the operation.

New hybrid procedure without opening the chest

The new hybrid procedure involves one abdominal cut, the divergence of the blood vessels branching from the diseased aorta to the kidneys, liver and intestines, and the insertion of an endoprosthesis into the aorta through one of the two femoral arteries. Computer tomography prior to surgery enables the bespoke design of the endoprostheses according to the patient’s individual requirements. On average, each patient is implanted with three endoprostheses. The hybrid procedure spares the patients from having their chest opened, from artificial cardiac arrest, the disconnection of the aorta as well as minimising blood loss.

Until March 2005, the two steps involved in the hybrid procedure were carried out simultaneously. Since then, the Heidelberg surgeons have moved towards two interventions with an interval of about seven days between the two. This is less stressful for patients and protects the spinal marrow from excessive oxygen deficiency. The second part of the procedure can usually be done under local anaesthetic by way of a small opening in the groin. For statistical reasons (i.e. low number of patients operated) no statements can be made on whether the two-tier method has a significant advantage over the one-tier method.

After surgery, the patients were thoroughly examined upon before they left hospital and at regular intervals thereafter for an average period of 22 months. The overall mortality of patients due to underlying illness or due to the consequences of the procedure was about 30 per cent (nine out of 28 patients). “Of course, it is difficult to compare this figure directly with the mortality of patients undergoing conventional surgery,” said Professor Dittmar Böckler. “The new procedure was only used for high-risk patients who could not undergo conventional surgery”. However, Böckler believes that the overall mortality will decrease the greater the international experience with the new hybrid procedure: “The key to success is the right selection of high-risk patients.”

Source: University Hospital Heidelberg- 28th May 2008
Böckler D. et al.: Hybrid Procedures for thoracoabdominal aortic aneurysms and chronic aortic dissections - a single center experience in 28 patients. In: Journal of Vascular Surgery, J Vasc Surg. 2008 Apr;47(4):724-32.
Further information:
Prof. Dr. med. Dittmar Böckler
Interim Medical Director
Hospital of Vascular Surgery
Department of Vascular and Endovascular Surgery
University Hospital Heidelberg
Tel.: +49 (0)6221 / 56-6249 (Secretariat)
E-mail: dittmar.boeckler@med.uni-heidelberg.de
Website address: https://www.gesundheitsindustrie-bw.de/en/article/news/life-saving-surgery-for-high-risk-patients