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Hybrid OR

New Options for Treating Complex Cardiovascular Conditions

By Lindy Keane Carter
Photography by Brennan Wesley

The Medical University of South Carolina (MUSC) has opened the state’s first hybrid operating room (OR) equipped with cutting-edge technology that gives cardiac and vascular surgeons dynamic, real-time, three-dimensional (3-D) reconstruction of a patient’s vascular anatomy. As a result, surgeons are able to combine endovascular procedures with conventional open surgery in one OR to treat even the most complex cardiac and vascular conditions.

“It’s definitely a game changer for South Carolina,” explains Joshua D. Adams, M.D., Chief of Endovascular Surgery and an Assistant Professor of Surgery and Radiology at MUSC. “This hybrid OR is a step ahead of other systems in that it gives us live 3-D angiographic guidance.” With this addition of imaging technology to MUSC clinicians’ technical expertise and quality postoperative follow-up care, MUSC has rounded out a comprehensive package of elite care available to the region’s heart and vascular patients.

The hybrid OR is equipped with state-of-the-art surgical equipment and advanced imaging technology software that gives cardiothoracic and vascular surgeons high-resolution visualization and angiographic guidance while they maneuver guide wires, catheters, and stents during complex procedures. The new imaging technology includes a robotic C-arm that spins 360 degrees around the patient and provides a Syngo DYNA CT® (Siemens USA, Malvern, PA), which is a three-dimensional roadmap of the patient’s vascular anatomy, allowing complex navigation of the vessels without administering additional contrast agent. Less contrast agent decreases the chances of kidney injury. Since this OR opened in September 2013, MUSC physicians have performed more than 50 intricate procedures via small incisions on dozens of patients who otherwise would have undergone open surgery.

For five decades, medicine has been pushing the limits of what could be accomplished with endovascular techniques, beginning with the first angioplasty in 1964. Benefits of an endovascular approach include less pain, less scarring, a shorter hospital stay (reducing complications and infection risk), and faster rehabilitation. Today, even a procedure as complicated as treatment of aortoiliac occlusive disease is accomplished with endovascular surgery—all through groin incisions to access the femoral arteries. Dr. Adams explains that, prior to endovascular surgery, the conventional operation was an aorta bifemoral bypass, in which the surgeon made a long midline abdominal incision, moved the bowels aside, dissected and clamped the aorta, tunneled down to the groin incisions, and sewed the two limbs of the graft onto the femoral arteries. Now, with minimally invasive surgery, the endovascular surgeon can avoid the abdominal portion of the operation and instead open the aorta and iliac arteries with covered stents that extend down to the cleaned-out femoral arteries in the groin. “Then, through those same incisions and during the same operation,” says Dr. Adams, “you can use the imaging to go the rest of the way down the leg and open up the arteries all the way to the foot.”

Complex Procedures Performed in the Hybrid OR

Dr. Joshua D. Adams Chief of Endovascular Surgery
Dr. Joshua D. Adams, Chief of Endovascular Surgery

Other conditions treated by Dr. Adams and his colleagues in the hybrid OR include thoracic aortic aneurysms, thoracic aortic dissections, thoracoabdominal aortic aneurysms, abdominal aortic aneurysms (AAAs), iliac artery aneurysms, and peripheral vascular disease. In addition, they treat patients whose anatomy makes them poor candidates for standard endovascular repair. For example, an estimated 50% of patients with AAAs are not candidates for endovascular repair using the conventional devices because of unfavorable anatomy, such as a short or angulated neck or complex aneurysmal involvement of the juxtarenal, perivisceral, or thoracoabdominal aorta.1 Before complex endovascular procedures for AAAs were possible, patients with large aneurysms and poor cardiac, pulmonary, or renal performance had only the option of certain operations to render the anatomy suitable for endovascular repair, but the open surgery required by this procedure carried a substantial morbidity and mortality risk.

Now, advanced endovascular techniques enable endovascular surgeons to use fenestrated and branched endografts to treat complex AAAs in high-risk patients. Thanks to the hybrid OR, MUSC is the only center in South Carolina that provides fenestrated stent grafts for treating complex AAAs. Dr. Adams is currently the only vascular surgeon in South Carolina certified to implant the Cook Medical (Bloomington, IN) Zenith® Fenestrated AAA Endovascular Graft. This will enable treatment of 15% to 20% more AAA patients who are ineligible for standard endovascular repair.

Dr. Adams, who assumed his position at MUSC in August 2013, is board-certified in interventional radiology and vascular surgery. His ten years of training enable him to tailor his treatment plan with either an open surgical approach, an endovascular approach, or a combination of the two.

Cardiothoracic surgeons also use the hybrid OR to perform traditional catheterization procedures, as well as more complex procedures, such as transcatheter aortic-valve replacement. This is a procedure for implanting a heart valve that does not require open heart surgery. “This new, state-of-the-art, hybrid OR will allow us to continue to expand our armamentarium of minimally invasive treatment options for heart disease, giving patients who seek care at MUSC many options for a tailored treatment approach,” says John S. Ikonomidis, M.D., PhD, Chief of the Division of Cardiothoracic Surgery in the Department of Surgery.

Having the ability to perform imaging studies in this kind of OR eliminates the need to move patients during a procedure, reducing the risk of infection and complications. Previously, the patient went to the OR for one portion of the procedure and then was moved to the angiographic suite for the endovascular surgery. This OR also facilitates quick, informed decision-making among the team of interventional cardiologists, cardiac surgeons, anesthesiologists, perfusionists, and radiologists. The ­imaging equipment allows the clinical team to evaluate the ­structures and repairs in real time so that they can begin more advanced operations immediately if necessary. In addition, it emits less radiation during the imaging process.

Technology and the Future

In the future, technology and device design may evolve to the point that endovascular surgeons will be able to treat pathology of the entire aorta, from the sinotubular junction to the aortic bifurcation, via an entirely endovascular approach. MUSC is committed to staying at the forefront of clinical innovation. “It’s very exciting to be part of the growth of endovascular surgery here at MUSC,” says Dr. Adams, “especially knowing that more and more patients will be able to benefit from fewer complications, shorter hospital stays, and a quicker return to a normal quality of life.”


1 Ricotta JJ. Fenestrated and branched stent-grafts for the treatment of thoracoabdominal aortic aneurysms: The future is now. J Endovasc Ther 2010;17:212-215.