1. No category

Dancing in hybrid OR
- surgeon’s perspective -
Kay-Hyun Park, MD
Thoracic and Cardiovascular Surgery
Seoul National University Bundang Hospital
Surgeons are not good at dancing,
not at angiography and catheters, either.
But, we need them.
Why ?
 To
reduce the complexity of procedure
 To
 To
save incision (trauma)
save time (esp. cardiopulmonary bypass)
 To
 To
confirm the result on site
have surveillance by anethesiologist
 To
have immediate surgical back-up
When ?
 Congenital

multiple VSD, aortopulmonary collaterals, pulmonary artery stenosis
 Valve

disease
TAVI
 Coronary


heart disease
artery disease
completion CAG
hybrid revascularization (MIDCAB + PCI)
 Arrhythmia


epicardial + endocardial ablation
pacemaker / ICD
 Aortic
repair
Difficult access
small vessel
tortuosity
occlusive disease
Case 1
Uni-iliac EVAR + FF bypass
• M / 79
• Right leg claudication
• Small AAA (4.8cm) – repair wanted
(백령도 거주)
• s/p PCI (LAD & RCA stents)
• Op time : 2hr 35min (Cath Lab)
• Total amount of contrast media : 120cc
Case 2
One-stage TEVAR + EVAR
• M / 74
• CC: Abdominal discomfort, claudication
• AAA + left EIA occlusion
retroperitoneal
exposure
Common iliac a. conduit
+ hypogastric a. translocation
• Op time : 5 hrs (Cath Lab)
• Total amount of contrast media (Ultravist® ) : 260cc
(CAG 50~80cc, CTO lesion 200cc, EVAR 150~200cc)
Case 3
TEVAR with carotid-subclavian bypass
• F / 75
• Severe acute chest & back pain
• s/p PCI (RCA & LCx stents)
One arterial access
could be saved.
LSCA can be ligated
instead of being plugged.
• Op time : 2hr 40min (Cath Lab)
• Total amount of contrast media : 120cc
Case 4
• colectomy for cecal cancer, pubic fracture
during 6 months after TEVER
• Fever & dyspnea 9 months after TEVAR
3 months
9 months
Case 5
• M / 76
• Total arch replacement with FET
+ CABG x2 (4 years ago)
postop 1 month
postop 4 years
aneurysm 5058mm
distal landing end 2635mm
• M / 57, saccular arch aneurysm
courtesy of Taek Yeon Lee, MD
Personal experience of arch replacement
(1998 ~ 2011)

Acute type A dissection

Arch replacement (+)
6 / 53 = 11.3%
6% if on-CPR patients are excluded

Arch replacement (-)
9 / 166 = 5.4%
3.1% if on-CPR patients are excluded

Elective arch replacement for non-dissection
8 / 95 = 8.4%
2 / 81 = 2.5% for isolated arch aneurysm

5 of mortality cases = arch~descending thoracic aorta replacement

2 of mortality cases = combined with multi-vessel CABG or double valve

> 60% if ruptured + in shock
Case 6
• M / 41
• Acute type A dissection
• + epigastric pain, nausea & vomiting
celiac trunk
sup. mesenteric a.





6 cm extension of sternotomy
Exposure of RGEA
transit-time ultrasonic flow ≈ 0 in RGEA
aorta graft – RGEA bypass with saphenous vein
graft flow = 90 ml/min
Hepatic & splenic infarction
narrow common hepatic a.
CT angiography of POD #1
Case 7
• F / 61
• Acute type A dissection + leg ischemia
Case 8
• M / 51
• Acute type A dissection
+ hemorrhagic infarction of brain
Case 9
• M / 39
• Acute type A dissection
+ leg ischemia & ARF
• s/p MVR + AVR (tissue valve) for
infective endocarditis, 3 years ago
• stent graft for the distal arch tear
stent for both iliac arteries 
• Surgery, 3 weeks later : Bentall + MVR
+ arch vessel transposition
adventitial
inversion
Case 10
CABG + hybrid arch repair
• M / 65
• s/p AAA repair
• Arch aneurysm with hoarseness
• Incidental 3-vessel CAD
• Op time : 6hr 50min
<< CABG x3 ≈ 3hr 30min + arch replacement ≈ 5hours
• Hospital stay : 12 days
Case 11
Hybrid replacement of entire thoracic aorta
• M / 86
• Severe back pain
X
distal graft deployed
with angiography
proximal graft deployed
with ‘eyeball’
• Op time : 4hr 50min
• Hospital stay : 58 days
• Alive (22 months)
Case 12
Disaster caused by lack of angiography
• M / 81
• Arch aneurysm rupture / shock
•
Outside CT covered thoracic aorta only.
Retrograde insertion
of guidewire failed.
Blind antegrade deployment
• Op time : 5hr 50min
• Died of cholesterol embolism  rhabdomyolysis  ARF
Traumatic aortic rupture
Why don’t we have the anesthesiologic back-up?
Endovascular aortic repair for surgeons
Creative mind
“Save time, incision, access, and dye”
Fun
“피할 수 없다면 즐기자”
Synergy
“相生”