title: Evolving practice pattern changes and outcomes in the era of hybrid aortic arch repair.
abstract: OBJECTIVE
  The role of hybrid repair in the management of aortic arch pathology, and long-term outcomes with these techniques, remains uncertain. We report a decade of experience with hybrid arch repair (HAR) and assess institutional practice patterns with regard to the use of hybrid and open techniques.
  
  
  METHODS
  Hybrid and open total and distal arch procedures performed between July 2005 and January 2015 were identified from a prospectively maintained, institutional aortic surgery database. Perioperative morbidity and mortality, freedom from reintervention, and long-term survival were calculated. Hybrid and open procedural volumes over the study period were assessed to evaluate for potential practice pattern changes.
  
  
  RESULTS
  During the study period 148 consecutive procedures were performed for repair of transverse and distal aortic arch pathology, including 101 hybrid repairs and 47 open total or distal arch repairs. Patients in the hybrid repair group were significantly older with a greater incidence of chronic kidney disease, peripheral vascular disease, and chronic lung disease. Perioperative mortality and outcomes were not significantly different between the hybrid and open groups, aside from decreased median length of stay after hybrid repair. Need for subsequent reintervention was significantly greater after hybrid repair. Unadjusted long-term survival was superior after open repair (70% 5-year survival open vs 47% hybrid; P = .03), although aorta-specific survival was similar (98% 5-year aorta-specific survival open vs 93% hybrid; P = .59). Institutional use of HAR decreased over the final 3 years of the study, with an associated increased use of open total or distal arch repairs. This was primarily the result of decreased use of native zone 0 hybrid procedures. Concurrent with this apparent increased stringency around patient selection for HAR, perioperative morbidity and mortality was reduced, including avoidance of retrograde type A dissection.
  
  
  CONCLUSIONS
  HAR remains a viable option for higher-risk patients with transverse arch pathology with perioperative outcomes and long-term aorta-specific survival similar to open repair, albeit at a cost of increased reintervention. This observational single-institution study would suggest decreased use in more recent years in favor of open repair due to avoidance of native zone 0 hybrid procedures. This decline in the institutional use of native zone 0 hybrid repairs was associated with improved perioperative outcomes.
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Ehsan
authors.initials: E
authors.lastname: Benrashid
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Hanghang
authors.initials: H
authors.lastname: Wang
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Jeffrey E
authors.initials: JE
authors.lastname: Keenan
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Nicholas D
authors.initials: ND
authors.lastname: Andersen
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: James M
authors.initials: JM
authors.lastname: Meza
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Richard L
authors.initials: RL
authors.lastname: McCann
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC. Electronic address: gchad.hughes@dm.duke.edu.
authors.forename: G Chad
authors.initials: GC
authors.lastname: Hughes
mesh_terms: D000328:Adult; D000368:Aged; D001013:Aorta, Thoracic / Q000601:surgery*; D001018:Aortic Diseases / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality / Q000639:trends*; D016208:Databases, Factual; D018572:Disease-Free Survival; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality / Q000639:trends*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009657:North Carolina; D018579:Patient Selection; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D010818:Practice Patterns, Physicians' / Q000639:trends*; D019233:Retreatment; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome