The Operating Theatre Journal - Journal - Page 14
THE CHANGE IN PRACTICE OF AORTIC PROCEDURES FOLLOWING
THE INTRODUCTION OF HYBRID THEATRE IN A TERTIARY CENTRE
Objective
Authors
Thiagarajan J1 MBChB, University of Liverpool
Ninkovic-Hall G1,2 MBChB, University of Liverpool
Neequaye S2, MBBS, BSc, MSc
Guidelines stated in The Vascular Society of Great Britain and Ireland
(VSBGI’s) service provision report (2021)1declared 24/7 access to hybrid
theatres as a minimum standard in all arterial centres in the UK. This
is supported by the NHS national specialty report (2018)2 that regional
arterial hubs are “ideally’ required to provide access within 30 minutes
to a hybrid theatre for ruptured abdominal aortic aneuryms (rAAA)3.
Af昀椀liations
1
School of Medicine, University of Liverpool, UK
2
Royal Liverpool University Hospitals Trust, Liverpool, UK
Corresponding author
Janaki Thiagarajan
Broom昀椀eld Hospital, Court Rd, Broom昀椀eld, Chelmsford CM1 7ET
Janaki.Thiagarajan2@nhs.net
Con昀氀icts of interest
None
Funding sources
None
Word count
2129
ARTICLE HIGHLIGHTS
Type of Research: Single centre, retrospective analysis of prospectively
collected data.
Key 昀椀ndings
Endovascular procedures increased from 61% (pre-hybrid) to 97% (new
hybrid theatres) (p < 0.05) and average dosage area product (DAP)
of radiation exposure reduced by 46% for FEVAR and by 25% for EVAS
following the implementation of hybrid theatres.
Take home message
Hybrid theatres enable a wider range of techniques for aortic
procedures, facilitate the appropriate drive towards endovascular
approach, and signi昀椀cantly reduce radiation dosing in complex FEVAR.
Table of Contents Summary
Implementation of hybrid theatre increased the proportion of
endovascular procedures and signi昀椀cantly reduced radiation dosing in
this retrospective cohort study of 1070 patients with abdominal aortic
aneurysms.
Abstract
The aim of this study is to compare treatment approach and radiation
exposure before and after the introduction of hybrid theatres.
Background
Hybrid theatres are an advanced procedural space that combine the
environment of a conventional operating theatre with the radiological
capabilities of an image guided interventional suite.
In this theatre you can 昀椀nd surgical equipment and management
systems, advanced integration with multiple monitors, and notably
the 昀椀xed C-arm. This is a 昀氀uoroscopy unit that provides a far superior
imaging quality to the mobile C arm and is capable of rendering crosssectional 3D imaging over real time 2D images. This has the bene昀椀t of
allowing surgeons to navigate the anatomy intra-operatively, reduce
contrast exposure during placement of complex endovascular grafts
and has the potential for reduced radiation exposure compared to
traditional CT and the 昀椀xed C-arm4. Intra-operative angiography
facilitates the detection and immediate revision of technical defects
and stent related complications (poor lie of the graft, 昀氀awed
anastomoses, bypasses to healthy vessels), therefore reducing the need
for early secondary intervention5. This is demonstrated by Biasi et al
(2009) in a prospective cohort study of 80 patients undergoing EVAR
where the 昀椀xed C-arm detected 昀椀ve clinically signi昀椀cant anomalies
intraoperatively that were not detected on completion angiography6.
Another advantage of the hybrid operating theatre is the ease of
transition from a minimally invasive to an open procedure under one
anaesthetic without needing to move the patient at this critical time7.
It is also important to consider the cost-effectiveness of allocating
supplies and staff to one space which prevents duplicated resources.
Some of the barriers for construction of hybrid theatre include
installation costs ($1.2-5 million), increased space requirements (1100
square feet as opposed to 600 square feet8), additional staff training
and the average of 2 years required to build the space.
Methods
Background
Hybrid theatres facilitate higher quality angiography and simultaneous
employment of open and endovascular techniques. We compared
treatment approaches and radiation exposure following hybrid theatre
introduction in January 2016.
Methods
6-year retrospective review of all aortic interventions (January 2015
- March 2021) at a single tertiary vascular unit, from a prospective
operative database. ‘Pre-hybrid’ cases in traditional theatres were
compared to those in the ‘post-hybrid’ period (hybrid and traditional
theatres).
Results
From 3885 vascular procedures, there were 184 aortic cases in the prehybrid period and 886 post-hybrid (hybrid theatre n=539, traditional
theatres n=369).
Proportionally, endovascular procedures increased from 61% (prehybrid) to 97% (new hybrid theatre) (p < 0.05).
Of the cases in traditional theatres, post hybrid introduction; 94% (347)
open and 6% (22) endovascular or combined.
212 (40%) of all endovascular cases in the hybrid setting were complex
(TEVAR, FEVAR, BEVAR & ChEVAR/ChEVAS). The average FEVAR DAP
vastly reduced following hybrid introduction (403 vs 233 (Gy cm²)
(p