title: Hybrid repair of complex thoracic aortic arch pathology: long-term outcomes of extra-anatomic bypass grafting of the supra-aortic trunk.
abstract: OBJECTIVE
  Hybrid repair constitutes supra-aortic debranching before thoracic endovascular aortic repair (TEVAR). It offers improved short-term outcome compared with open surgery; however, longer-term studies are required to assess patient outcomes and patency of the extra-anatomic bypass grafts.
  
  
  METHODS
  A prospectively maintained database of 380 elective and urgent patients who had undergone TEVAR (1997-2011) was analyzed retrospectively. Fifty-one patients (34 males; 17 females) underwent hybrid repair. Median age was 71 (range, 18-90) years with mean follow-up of 15 (range, 0-61) months.
  
  
  RESULTS
  Perioperative complications included death: 10 % (5/51), stroke: 12 % (6/51), paraplegia: 6 % (3/51), endoleak: 16 % (8/51), rupture: 4 % (2/51), upper-limb ischemia: 2 % (1/51), bypass graft occlusion: 4 % (2/51), and cardiopulmonary complications in 14 % (7/51). Three patients (6 %) required emergency intervention for retrograde dissection: (2 aortic root repairs; 2 innominate stents). Early reintervention was performed for type 1 endoleak in two patients (2 proximal cuff extensions). One patient underwent innominate stenting and revision of their bypass for symptomatic restenosis. At 48 months, survival was 73 %. Endoleak was detected in three (6 %) patients (type 1 = 2; type 2 = 1) requiring debranching with proximal stent graft (n = 2) and proximal extension cuff (n = 1). One patient had a fatal rupture of a mycotic aneurysm and two arch aneurysms expanded. No bypass graft occluded after the perioperative period.
  
  
  CONCLUSIONS
  Hybrid operations to treat aortic arch disease can be performed with results comparable to open surgery. The longer-term outcomes demonstrate low rates of reintervention and high rates of graft patency.
authors.affiliation: Vascular Surgery, Guy's and St. Thomas' NHS Trust, London, SE1 7EH, United Kingdom. shamim.lotfi@kcl.ac.uk
authors.forename: S
authors.initials: S
authors.lastname: Lotfi
authors.forename: R E
authors.initials: RE
authors.lastname: Clough
authors.forename: T
authors.initials: T
authors.lastname: Ali
authors.forename: R
authors.initials: R
authors.lastname: Salter
authors.forename: C P
authors.initials: CP
authors.lastname: Young
authors.forename: R
authors.initials: R
authors.lastname: Bell
authors.forename: B
authors.initials: B
authors.lastname: Modarai
authors.forename: P
authors.initials: P
authors.lastname: Taylor
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000792:Angiography / Q000379:methods; D001013:Aorta, Thoracic / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods / Q000401:mortality*; D015331:Cohort Studies; D016208:Databases, Factual; D057867:Endoleak / Q000453:epidemiology; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000379:methods / Q000401:mortality; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods; D010264:Paraplegia / Q000453:epidemiology; D011183:Postoperative Complications / Q000175:diagnosis / Q000401:mortality; D011379:Prognosis; D011475:Prosthesis Failure; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D015607:Stents; D020521:Stroke / Q000453:epidemiology; D016019:Survival Analysis; D014057:Tomography, X-Ray Computed / Q000379:methods; D006113:United Kingdom; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000379:methods; D055815:Young Adult