Hybrid Approaches to Complex Aortic Arch Aneurysms

Abstract

The management of aortic arch aneurysms remains a clinical challenge. Although open operative techniques have been refined with improving results over the last 2 decades, neurologic and cardiovascular complications remain significant causes of morbidity and mortality. This is related to the requirement for hypothermic circulatory arrest with adjunct cerebral perfusion strategies during open aortic arch surgery. In patients thought to be at prohibitively high risk for conventional repair, an alternative therapy is much desired. The recent introduction of thoracic aortic endovascular stent grafting (TEVAR) has provided an alternative surgical option in patients felt to be at prohibitively high risk for conventional open aortic arch repair. Combining conventionalsurgicaltechniqueswithendovasculartechnology,this so-called “hybrid” aortic arch repair seeks to minimize the “operation” by either eliminating or significantly simplifying and shortening the arch reconstruction, thus limiting the duration of circulatory arrest and cerebral ischemia. The arch hybrid repair is a landing zone “0” endovascular repair of the aortic arch and is guided by the 2 following fundamental concepts: (1) brachiocephalic bypass, or revascularization of the great vessels; (2) construction of optimal proximal and distallandingzonesforTEVAR.Therefore,archhybridrepair comprises open surgical techniques for great vessel revascularization and landing zone reconstruction along with endovascular stent grafting performed concomitantly or at a later time. The arch hybrid repair is especially appealing in older patients and in those with significant comorbidities who may not tolerate prolonged cardiopulmonary bypass and circulatory arrest. This report focuses on aortic arch hybrid operative techniques.