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Objective: Many patients with aortic dissection develop Crawford extent I or II thoracoabdominal aortic aneurysms (TAAA). Because open repair is associated with a high morbidity and mortality, hybrid approaches to TAAA repair are emerging. In this study, we evaluated the midterm outcomes and aortic remodeling of a hybrid technique that combines proximal thoracic endovascular aneurysm repair (TEVAR), followed by staged distal open thoracoabdominal repair for patients with Crawford extent I or II TAAAs secondary to chronic aortic dissection., Methods: We identified 19 patients with Crawford extent I (n = 1) or extent II (n = 18) TAAAs secondary to chronic aortic dissection who underwent a staged hybrid repair from 2007 to 2014 at our institution. Nine patients had previous open ascending aortic surgery for type I aortic dissection. Stage 1 TEVAR was performed via percutaneous (n = 8), femoral cutdown (n = 8), or iliac exposure (n = 3). The left subclavian artery was covered in nine patients and revascularized in eight patients using carotid-subclavian bypass (n = 7) or laser fenestration (n = 1). Stage 2 open repair was performed a median of 18 weeks later with partial cardiopulmonary bypass via left femoral arterial and venous cannulation for visceral and lower body perfusion. The open thoracoabdominal graft was anastomosed proximally in an end to end fashion with the endograft. We then assessed surgical morbidity and mortality, midterm survival, and freedom from reintervention. Aortic remodeling was measured and change in maximum aortic and false lumen diameter at last follow-up (median, 3 years) from baseline was assessed., Results: There were no deaths, strokes, or chronic renal failure in this cohort. After stage 1 TEVAR, three patients required repeat intervention for endoleak (type Ia, n = 1; type Ib, n = 1; type II, n = 1) before open repair. After stage 2 open repair, there was a single delayed permanent paralysis 2 weeks after discharge. At a median 3-year follow-up (range, 6 months-6.2 years), there were no deaths, neurologic events, endoleaks, or TAAA reinterventions. Complete false lumen thrombosis occurred in 100% of the patients, with maximum false lumen diameter decreasing from 34.3 ± 15.3 mm to 13.2 ± 12.0 mm (P < .01) and total aortic diameter decreasing from 60.2 ± 9.0 mm to 49.4 ± 9.6 mm (P < .01)., Conclusions: Staged hybrid TAAA repair, using a combination of proximal TEVAR with open distal repair, can be performed using established endovascular skills and technology coupled with traditional open aortic surgical techniques, with low surgical morbidity and mortality. In the midterm, staged hybrid TAAA repair was associated favorable survival, aortic remodeling, and freedom from reintervention., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Descending thoracic aortic diseases may be treated with either open thoracic aortic repair or thoracic endovascular aortic repair (TEVAR). Previous studies have demonstrated that race and socioeconomic status (SES) affect access to care and treatment allocation in vascular surgery. We hypothesized that racial minorities and lower SES patients have decreased propensity to have their thoracic aortic disease treated with TEVAR., Methods: Weighted discharge records for patients who underwent either open thoracic aortic repair or TEVAR between 2005 and 2008 were evaluated using the Nationwide Inpatient Sample. Patient records were stratified by therapeutic intervention (open repair vs TEVAR). Differences in baseline comorbidities, race, and SES were compared. To account for the effects of comorbidities and other factors, hierarchical logistic regression modeling was used to determine the likelihood for TEVAR performance based on differences in patients' race and SES., Results: A total of 60,784 thoracic repairs were analyzed, the majority (79.4%) of which were open repairs. The most common race was white (78.2%), followed by black (9.1%), Hispanic (5.7%), Asian or Pacific Islander (2.9%), and Native American (0.7%). Patients were divided into quartiles according to SES with 20.6% of patients in the lowest SES quartile, 24.3% in the second quartile, 26.4% in the third quartile, and 28.8% in the highest SES quartile. Indications for treatment were similar for both treatment groups. After adjusting for multiple patient and hospital factors, race and SES were significantly associated with treatment modality for thoracic aortic disease. Black, Hispanic, and Native American populations had increased adjusted odds ratios of TEVAR performance compared with white patients. Similarly, lower SES correlated with increased use of TEVAR., Conclusions: Contrary to our initial hypothesis, racial minorities (Black, Hispanic, and Native American) and patients with lower median household incomes have a greater association with the performance for TEVAR after accounting for patient comorbid disease, indication for treatment, payer status, and hospital volume. These results indicate that traditional racial disparities do not persist in TEVAR allocation., (Copyright © 2013. Published by Mosby, Inc.)