What is the TAMBE (Transcatheter Aortic Valve Replacement, Mitral Valve Repair, Endovascular Aneurysm Repair) approach to abdominal aortic aneurysm (AAA) repair?

The TAMBE Approach to Abdominal Aortic Aneurysm Repair

The TAMBE (Transcatheter Aortic Valve Replacement, Mitral Valve Repair, Endovascular Aneurysm Repair) approach is not a recognized standard protocol for AAA repair in current vascular surgery guidelines, as it combines cardiac valve procedures with endovascular aneurysm repair in a single staged or hybrid intervention. Instead, endovascular aneurysm repair (EVAR) is the preferred approach for AAA with suitable anatomy and in patients with reasonable life expectancy (>2 years) according to the most recent guidelines 1.

Current Standard of Care for AAA Repair

Endovascular Aneurysm Repair (EVAR)

• EVAR is recommended as the preferred therapy for patients with suitable anatomy and reasonable life expectancy (>2 years) 1
• Benefits of EVAR include:
  • Reduced perioperative mortality (<1% vs 4-5% with open repair) 1
  • Shorter hospital stay and decreased perioperative morbidity 1
  • Less invasive approach with quicker recovery time

Open Surgical Repair

• Traditional approach through midline laparotomy with Dacron graft placement 1
• Still indicated for:
  • Patients with unsuitable anatomy for EVAR
  • Young, low-risk patients who may benefit from the durability of open repair
  • Cases where EVAR has failed

Decision-Making Algorithm for AAA Repair

1. Determine need for intervention:

   • Elective repair is recommended when:
     • AAA diameter ≥55 mm in men or ≥50 mm in women 1
     • Saccular aneurysm ≥45 mm may be considered 1
     • Growth ≥5 mm in 6 months or ≥10 mm per year may warrant repair 1

2. Assess patient factors:

   • Life expectancy (repair not recommended if <2 years) 1
   • Surgical risk profile
   • Comorbidities

3. Evaluate anatomical suitability for EVAR:

   • Proximal neck morphology (length >10-15 mm, diameter <30 mm) 1
   • Iliac access vessels
   • Presence of mural thrombus/calcification

4. Choose appropriate approach:

   • For ruptured AAA with suitable anatomy: EVAR is recommended over open repair 1
   • For elective repair with suitable anatomy: EVAR should be considered 1
   • For complex anatomy: Consider fenestrated or branched endografts 1

Important Considerations and Pitfalls

Pre-operative Assessment

• Complete vascular evaluation including the entire aorta is mandatory 1
• CT angiography is the optimal pre-operative imaging modality 1
• DUS assessment of femoro-popliteal segment should be considered to detect concomitant aneurysms 1
• Routine coronary angiography and revascularization before AAA repair is not recommended 1

Post-EVAR Surveillance

• Mandatory lifelong surveillance due to risk of endoleaks and late complications 1
• Follow-up imaging at 1 month and 12 months post-operatively, then yearly 1
• Five types of endoleaks can occur, with Type I and III requiring prompt correction 1

Common Pitfalls

• Underestimating the importance of neck morphology in EVAR planning
• Failing to detect concomitant femoro-popliteal aneurysms
• Inadequate post-EVAR surveillance leading to missed endoleaks
• Performing repair in patients with limited life expectancy (<2 years) 1

Conclusion on TAMBE Approach

While the TAMBE approach (combining TAVR, mitral valve repair, and EVAR) is not specifically described in current guidelines, the concept of addressing multiple cardiovascular pathologies in a coordinated manner may be relevant for select patients with both valvular heart disease and AAA. However, the standard approach remains to treat AAA according to established guidelines based on aneurysm size, growth rate, patient factors, and anatomical considerations, with EVAR being the preferred option when feasible 1.