title: A systematic review and meta-analysis of hybrid aortic arch replacement.
abstract: BACKGROUND
  Evolution in the endovascular era has influenced the management of aortic arch pathologies. Several studies have described the use of a combined endovascular and open surgical approach to the treatment of arch diseases. Hybrid repair of arch pathologies has been considered as a less invasive method, and is therefore an appealing option for high-risk patients who are unsuitable for open repairs. The aim of the present meta-analysis was to assess the efficacy of hybrid techniques in patients with aortic arch pathologies.
  
  
  METHODS
  Extensive electronic literature search was undertaken to identify all articles published up to December 2012 that described hybrid aortic arch repair with intrathoracic supra-aortic branch revascularisation and subsequent stent graft deployment. Eligible studies were divided into two groups: group I included studies on the aortic arch debranching procedure and group II included studies that reported an elephant trunk technique (either "frozen" or stented). Separate meta-analyses were conducted in order to assess technical success, stroke, spinal cord ischemia (SCI), renal failure requiring dialysis, and cardiac and pulmonary complications rate, as well as 30-day/in-hospital mortality.
  
  
  RESULTS
  Forty-six studies were eligible for the present meta-analysis: 26 studies with a total of 956 patients reported aortic arch debranching procedures, and 20 studies with 1,316 patients performed either 'frozen' or stented elephant trunk technique. The pooled estimate for 30-day/in-hospital mortality was 11.9% for the arch debranching group and 9.5% for the elephant trunk group. Cerebrovascular events of any severity were found to have occurred postoperatively at a pooled rate of 7.6% and 6.2%, while irreversible spinal cord injury symptoms were present in a pooled estimate of 3.6% and 5.0% in the arch debranching and elephant trunk group, respectively. Renal failure requiring dialysis occurred at 5.7% and 3.8% in both groups, while cardiac complications rate was 6.0% in the arch debranching cohort and pulmonary complication was 19.7% in the elephant trunk cohort.
  
  
  CONCLUSIONS
  Hybrid arch techniques provide a safe alternative to open repair with acceptable short- and mid-term results. However, stroke and mortality rates remain noteworthy. Future prospective trials that compare open conventional techniques with the hybrid method or the entirely endovascular methods are needed.
authors: Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece; ; The Systematic Review Unit, The Collaborative Research (CORE) Group, Sydney, Australia;
authors: Konstantinos G
authors: KG
authors: Moulakakis
authors: Spyridon N
authors: SN
authors: Mylonas
authors: Fotis
authors: F
authors: Markatis
authors: Thomas
authors: T
authors: Kotsis
authors: John
authors: J
authors: Kakisis
authors: Christos D
authors: CD
authors: Liapis
keywords: Aortic arch; debranching; frozen elephant trunk; hybrid; stented elephant trunk
references: Ann Thorac Surg. 2012 May;93(5):1517-22
references: 22443864
references: Eur J Vasc Endovasc Surg. 2011 Oct;42(4):456-63
references: 21788141
references: Ann Vasc Surg. 2011 Jul;25(5):598-604
references: 21131174
references: J Thorac Cardiovasc Surg. 2012 May;143(5):1007-13
references: 21783209
references: Ann Thorac Surg. 2012 Jul;94(1):84-9
references: 22595468
references: Ann Thorac Surg. 2012 Jan;93(1):103-9; discussion 109
references: 22088418
references: Ann Thorac Surg. 2011 Feb;91(2):465-71
references: 21256293
references: J Thorac Cardiovasc Surg. 2011 Dec;142(6):1458-63
references: 21458010
references: J Thorac Cardiovasc Surg. 2009 Jul;138(1):46-52; discussion 52-3
references: 19577055
references: J Thorac Cardiovasc Surg. 2010 Jul;140(1):52-8
references: 19919865
references: Eur J Cardiothorac Surg. 2011 Nov;40(5):1066-71
references: 21511488
references: Eur J Vasc Endovasc Surg. 2010 Dec;40(6):715-21
references: 20920861
references: Control Clin Trials. 1986 Sep;7(3):177-88
references: 3802833
references: Eur J Cardiothorac Surg. 2013 Feb;43(2):406-10
references: 22653445
references: Ann Thorac Surg. 1999 Jun;67(6):1874-8; discussion 1891-4
references: 10391330
references: Chin Med J (Engl). 2011 Oct;124(19):3003-7
references: 22040544
references: Ann Thorac Surg. 2009 Feb;87(2):603-7
references: 19161789
references: J Thorac Cardiovasc Surg. 2013 Apr;145(4):964-969.e1
references: 22507842
references: Rev Bras Cir Cardiovasc. 2010 Jul-Sep;25(3):303-10
references: 21103737
references: Biometrics. 1994 Dec;50(4):1088-101
references: 7786990
references: J Vasc Surg. 2013 Mar;57(3):655-67; discussion 666-7
references: 23186868
references: J Thorac Cardiovasc Surg. 2011 Nov;142(5):1084-9
references: 21616508
references: Cardiovasc Intervent Radiol. 2013 Feb;36(1):46-55
references: 22526104
references: Ann Thorac Surg. 2008 Nov;86(5):1524-9
references: 19049743
references: J Vasc Surg. 2012 Feb;55(2):318-25
references: 22047829
references: Ann Thorac Surg. 2007 Feb;83(2):S819-23; discussion S824-31
references: 17257934
references: Eur J Vasc Endovasc Surg. 2010 Dec;40(6):709-14
references: 20870433
references: J Thorac Cardiovasc Surg. 2006 Feb;131(2):336-42
references: 16434262
references: Ann Thorac Surg. 2009 Dec;88(6):1882-7; discussion 1887-8
references: 19932255
references: J Endovasc Ther. 2010 Feb;17(1):1-11
references: 20199258
references: Eur J Cardiothorac Surg. 2012 Jan;41(1):177-82
references: 21820909
references: J Vasc Surg. 2006 Sep;44(3):460-466
references: 16950417
references: J Vasc Surg. 2010 Jun;51(6):1329-38
references: 20303695
references: Ann Thorac Surg. 2009 Aug;88(2):482-9; discussion 489-90
references: 19632398
references: J Thorac Cardiovasc Surg. 2013 Jan;145(1):305-6
references: 23040321
references: Eur J Cardiothorac Surg. 2009 Dec;36(6):956-61
references: 19589693
references: JAMA. 2000 Apr 19;283(15):2008-12
references: 10789670
references: J Vasc Surg. 2011 Apr;53(4):935-41
references: 21215585
references: J Vasc Surg. 2008 Sep;48(3):571-9
references: 18639423
references: Interact Cardiovasc Thorac Surg. 2010 Nov;11(5):594-8
references: 20716557
references: J Cardiovasc Surg (Torino). 2011 Oct;52(5):717-23
references: 21894139
references: J Vasc Surg. 2010 Apr;51(4):836-41
references: 20347679
references: Eur J Vasc Endovasc Surg. 2006 Jul;32(1):38-45
references: 16520069
references: Ann Vasc Surg. 2012 Oct;26(7):1014-21
references: 22944571
references: Thorac Cardiovasc Surg. 1983 Feb;31(1):37-40
references: 6189250
references: Circulation. 2011 Mar 8;123(9):971-8
references: 21339481
references: J Thorac Cardiovasc Surg. 2008 Jun;135(6):1261-9
references: 18544367
references: J Thorac Cardiovasc Surg. 2013 Feb;145(2):349-54; discussion 354-5
references: 23142120
references: J Thorac Cardiovasc Surg. 2010 Dec;140(6 Suppl):S77-80; discussion S86-91
references: 21092802
references: Surg Today. 2012 Aug;42(8):765-9
references: 22318637
references: J Endovasc Ther. 2002 Jun;9 Suppl 2:II98-105
references: 12166849
references: J Cardiovasc Surg (Torino). 2012 Apr;53(2):143-51
references: 22456635
references: Ann Thorac Surg. 2004 Jun;77(6):2021-8
references: 15172258