title: Hybrid aortic arch repair for complicated type B aortic dissection.
abstract: OBJECTIVE
  This study analyzed the outcome of a combined endovascular and debranching procedure for hybrid aortic arch repair (HAR) in patients with complicated type B aortic dissection.
  
  
  METHODS
  Between February 2006 and August 2012, HAR was performed in 75 consecutive patients, with retrospective analysis of a subgroup of 45 patients who underwent HAR with complicated acute (n = 10), subacute (n = 7), or chronic (n = 28) type B dissection as the underlying disease. Descriptive statistics were computed for continuous and categoric variables. The interval to death or last follow-up was estimated using the Kaplan-Meier method.
  
  
  RESULTS
  The patients were a mean age of 59.9 ± 10.7 years (median, 59.2; range, 35-78 years). Complete supra-aortic debranching was performed in six (13%) in zone 0 (procedure time, 200 minutes; range, 185-365 minutes) and partial debranching in 39 (87%), comprising 16 (36%) in zone 1 (procedure time, 120 minutes; range, 75-250 minutes) and 23 (51%) in zone 2 (procedure time, 91 minutes; range, 70-210 minutes). Technical success was achieved in 86.7% (39 of 45). Thirty-day mortality was 4.4% (two of 45), with an in-hospital mortality of 11.1% (five of 45) as a result of three additional deaths after days 33, 35, and 111. Comparing HAR for type B dissection after complete debranching in six and partial debranching in 39, the overall in-hospital mortality was 67% (four of six) and 2.6% (one of 39), respectively. After a median follow-up of 20.8 months (range, 0.3-70 months), the overall mortality was 13.3% (six of 45), with Kaplan-Meier survival estimate of 85% at 1 year. Stroke rate was 8.8% (four of 45). Paraplegia developed in one patient (2.2%), with complete recovery after spinal drainage. Cardiac complications occurred in three patients (6.7%), pulmonary complications in 10 (22.2%), and renal insufficiency requiring dialysis developed in five (11%). Retrograde dissection occurred in one patient (2.2%) 14 days after complete debranching and zone 0 thoracic endovascular aortic repair, with fatal outcome. No bypass dysfunction was seen during follow-up. The overall early and late endoleak rates were 27% (12 of 44) and 43% (13 of 30), respectively. Eight patients (18%) required reintervention, with freedom of reintervention in 91% at 1 year and 81% at 2 years.
  
  
  CONCLUSIONS
  HAR in zone 1 and 2 appears a viable alternative to conventional aortic arch surgery in patients with complicated type B dissection. Stroke and endoleaks remain complications that need to be addressed. Treatment of type B aortic dissection with complete supra-aortic debranching and thoracic endovascular aortic repair in zone 0, however, is associated with high mortality, which might be reduced by improved technology using branched stent grafts.
authors.affiliation: Department of Surgery, Vascular Section, University of Rostock, Rostock, Germany. Electronic address: carsten.buenger@vivantes.de.
authors.forename: Carsten M
authors.initials: CM
authors.lastname: Bünger
authors.forename: Stephan
authors.initials: S
authors.lastname: Kische
authors.forename: Andreas
authors.initials: A
authors.lastname: Liebold
authors.forename: Maximilian
authors.initials: M
authors.lastname: Leißner
authors.forename: Aenne
authors.initials: A
authors.lastname: Glass
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Schareck
authors.forename: Hüseyin
authors.initials: H
authors.lastname: Ince
authors.forename: Christoph A
authors.initials: CA
authors.lastname: Nienaber
mesh_terms: D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001027:Aortography; D001807:Blood Vessel Prosthesis; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D005858:Germany / Q000453:epidemiology; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D015607:Stents; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome