Evolving paradigm of hybrid repair for aortic arch pathologies

Abstract

Background: Critical domain of thoracic aorta, the aortic arch, is affected by diverse pathologies mandating effective yet less strenuous management to save life, preserve organ function, and provide quality of life. Conventional open repair, minimally invasive total endovascular, and hybrid aortic arch repair are therapeutic options available. We present our experience and results with hybrid arch procedures. Materials and Methods: A cohort of 75 patients who were operated upon by the senior author from 2007 to 2020 formed the basis for this report. Male: female ratio was 11:1 for this group whose age ranged from 22 to 82 years with a mean of 70. Clinical indications were degenerative aneurysm (n = 49), Stanford B aortic dissection (n = 21), residual lesion following earlier Stanford A repair (n = 4) and a solitary patient with aortic trauma. Pan-arch debranching or hemi-arch debranching was performed in nearly all along with deployment of stent-graft at Zone 0 or Zone I, respectively. Sixty-seven elective (89.3%) procedures were staged and 8 (10.7%) were synchronous on account of being emergency interventions. Postoperative follow-up was performed at 3 and 6 months and yearly. Computed tomography aortogram was done before discharge from hospital or within 1 month followed by 1 year. Results: Technical success was achieved in 97.3%. Inhospital/30-day mortality was 9.3% (7/75 patients). Neurological complications, albeit less common, were the leading cause of perioperative morbidity. No endoleaks or graft migration was encountered in follow-up. Late mortality occurred in 10.3% (7/68 patients) from 6 months to 5 years, with massive hemoptysis in three despite asymptomatic clinical status and satisfactory imaging. Two patients were lost for follow-up, while the rest 59 patients are keeping well. Conclusion: Hybrid repair of aortic arch lesions, though initially intended to compliment stressful conventional surgery, has now evolved as the primary modality in this domain. This relatively safe therapeutic option, performed in a staged setting coupled with attention to achieve a liberal proximal seal, provided excellent initial results and long-term survival.