title: Hybrid approach to complex thoracic aortic aneurysms in high-risk patients: surgical challenges and clinical outcomes.
abstract: BACKGROUND
  Endovascular therapy is a less invasive alternative treatment for high-risk patients with thoracic aortic aneurysms. However, this technology alone is often not applicable to complex aneurysmal morphology. The purpose of this study was to evaluate the utility of hybrid strategies in high-risk patients who are otherwise unsuitable for endovascular therapy alone.
  
  
  METHODS
  During an 18-month period, 31 high-risk patients (mean age, 69 years; range, 52-89 years) underwent combined open and endovascular approaches for complex aneurysms, including 16 patients with ascending and arch aneurysms and 15 patients with aneurysms involving visceral vessels. Among them, 11 patients had histories of aneurysm repairs. To overcome the anatomic limitations of endovascular repairs, various adjunctive surgical maneuvers were used, including aortic arch reconstruction in 3 patients, supra-aortic trunk debranching in 13 patients (including 8 patients who required aortas as inflow sources), and visceral vessel bypasses in 15 patients (including 10 patients who required bypasses to all 3 visceral branches). Additionally, carotid artery access was obtained in 1 patient, and iliac artery conduits were created in 12 patients.
  
  
  RESULTS
  Technical success was achieved in all patients. There was one perioperative death (3.2%) due to postoperative bleeding. Two patients (6.4%) had immediate type II endoleaks, which were resolved by the 1-month follow-up. Other procedure-related complications occurred in three patients (9.6%), including renal bypass thromboses in two patients and retroperitoneal hematoma, which was successfully managed conservatively, in one patient. During a mean follow-up of 16 months, two patients died of unrelated causes, whereas the remainder of patients were asymptomatic, without aneurysm enlargement.
  
  
  CONCLUSIONS
  Our study highlights how hybrid strategies incorporating surgical and endovascular approaches can be used successfully in treating patients with complex thoracic aortic aneurysms. This combined approach potentially expands the field of endovascular stent grafting and is an attractive solution for patients with poor cardiopulmonary reserves.
authors.affiliation: Division of Vascular Surgery & Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA. wzhou1@bcm.edu
authors.forename: Wei
authors.initials: W
authors.lastname: Zhou
authors.forename: Michael
authors.initials: M
authors.lastname: Reardon
authors.forename: Eric K
authors.initials: EK
authors.lastname: Peden
authors.forename: Peter H
authors.initials: PH
authors.lastname: Lin
authors.forename: Alan B
authors.initials: AB
authors.lastname: Lumsden
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000601:surgery*; D001027:Aortography; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D005500:Follow-Up Studies; D006801:Humans; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome