title: Hybrid approaches in the treatment of aortic arch aneurysms: postoperative and midterm outcomes.
abstract: BACKGROUND
  The combined open surgical and endovascular approach for the treatment of aortic arch aneurysms has emerged as a safe treatment modality. This platform may have an especially important role in treating patients of old age and with a greater comorbid burden. We describe our institutional experience with the hybrid aortic arch approach, with midterm outcomes.
  
  
  METHODS
  From 2005 to the present, 685 patients have undergone thoracic endovascular repair (TEVAR); 104 had a hybrid arch repair (open plus endovascular approach). Of these, 47 patients had treatment for an aortic arch aneurysm with or without a proximal ascending aortic aneurysm. All these patients had a median sternotomy approach for arch vessel debranching and antegrade with or without retrograde TEVAR stent grafting of the arch. Results from a prospectively maintained database are reported.
  
  
  RESULTS
  Twenty-eight patients had type I repair, 8 patients had type II repair, and 11 patients had type III arch hybrid repair. Those with type III repair were excluded from the analysis. Stent graft deployment rate was 100% after arch vessel debranching. Mean age was 71 ± 8 years. Fourteen percent of cases involved a redo sternotomy. Average cardiopulmonary bypass time was 215 ± 64 minutes, with a crossclamp time of 70 ± 55 minutes and a circulatory arrest time of 19 ± 10 minutes. The paraplegia rate was 5.5% (n = 2), with a stroke rate of 8% (n = 3). In-hospital mortality was 8% (n = 3). There were no postoperative endoleaks. The mean length of stay was 17.2 ± 14 days. The median follow-up was 30 ± 21 months. Freedom from all-cause mortality was 71%, 60%, and 48% at 1, 3, and 5 years, respectively. The aortic reoperation rate was 2.7% (n = 1). No patient has a type 1 or 3 endoleak at latest follow-up.
  
  
  CONCLUSIONS
  The hybrid approach to aortic arch aneurysm involving a zone 0 stent graft landing can be safely adopted with good midterm results in a cohort of old patients with significant comorbidity. This procedure can be performed with no type 1 or 3 endoleaks and may represent a technical advancement in the field of aortic arch surgery.
authors.affiliation: Division of Cardiovascular Surgery, University of Pennsylvania Medical Center, Philadelphia, Pa, USA joseph.bavaria@uphs.upenn.edu
authors.forename: Joseph
authors.initials: J
authors.lastname: Bavaria
authors.forename: Prashanth
authors.initials: P
authors.lastname: Vallabhajosyula
authors.forename: Patrick
authors.initials: P
authors.lastname: Moeller
authors.forename: Wilson
authors.initials: W
authors.lastname: Szeto
authors.forename: Nimesh
authors.initials: N
authors.lastname: Desai
authors.forename: Alberto
authors.initials: A
authors.lastname: Pochettino
mesh_terms: D000368:Aged; D001013:Aorta, Thoracic / Q000601:surgery*; 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; D057867:Endoleak / Q000209:etiology; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005260:Female; D006324:Heart Arrest, Induced; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D010264:Paraplegia / Q000209:etiology; D015143:Philadelphia; D012086:Reoperation; D012307:Risk Factors; D015607:Stents; D056346:Sternotomy; D020521:Stroke / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome