title: Classic hybrid evolving approach to distal arch aneurysms: toward the zone zero solution.
abstract: BACKGROUND
  A combined open surgical and endovascular approach to managing aneurysms of the distal aortic arch (hybrid arch repair) is evolving as a viable treatment option. Our aim is to describe a treatment strategy in high-risk patients and report the technical and clinical success of the hybrid approach to aneurysms involving the distal aortic arch.
  
  
  METHODS
  From July 2005 until December 2009, 27 consecutive patients with aneurysms of the distal aortic arch were treated via a hybrid arch repair. Of this group, 23 patients underwent aortic arch debranching and revascularization before endovascular stent deployment in the ascending aorta (type I). Four patients required ascending aortic and transverse arch replacement before stent graft deployment (type II).
  
  
  RESULTS
  A stent graft was successfully deployed in 100% of patients after aortic arch vessel debranching via median sternotomy. The mean age of the patients was 71 ± 7.5 years. The average cardiopulmonary bypass time was 199 ± 84 minutes with an average crossclamp time of 57 ± 53 minutes. Deep hypothermic circulatory arrest was required in 4 patients (all type II). The average length of stay was 17.2 ± 14 days. The complications included stroke in 3 (11%) patients, permanent paralysis in 2 (7%), and perioperative death in 3 (11%) patients.
  
  
  CONCLUSIONS
  Early results of type I and II hybrid arch repair, in this cohort of patients with mutiple comorbid risk factors, are acceptable and even encouraging. This evolving approach to aneurysms involving the aortic arch may extend the indications for use of endovascular prostheses in the treatment of patients with complex aortic arch disease.
authors.affiliation: Hospital of the University of Pennsylvania, Department of Surgery, Philadelphia, PA, USA.
authors.forename: Joseph
authors.initials: J
authors.lastname: Bavaria
authors.forename: Rita K
authors.initials: RK
authors.lastname: Milewski
authors.forename: Joshua
authors.initials: J
authors.lastname: Baker
authors.forename: Patrick
authors.initials: P
authors.lastname: Moeller
authors.forename: Wilson
authors.initials: W
authors.lastname: Szeto
authors.forename: Alberto
authors.initials: A
authors.lastname: Pochettino
mesh_terms: D000368:Aged; D017545:Aortic Aneurysm, Thoracic / Q000401:mortality / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D002315:Cardiopulmonary Bypass; D050792:Circulatory Arrest, Deep Hypothermia Induced; D003131:Combined Modality Therapy; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010243:Paralysis / Q000209:etiology; D018579:Patient Selection; D015143:Philadelphia; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome