Hybrid Arch Research Articles

Single-Stage Hybrid Repair of Right Aortic Arch With Kommerell’s Diverticulum

Kommerell diverticulum is uncommon, and it carries risks of dissection or rupture. Hybrid aortic arch repair is being used increasingly for this pathology. We report the hybrid arch repair of Kommerell diverticulum in a 72-year-old woman known for muscular dystrophy and right aortic arch with aberrant left subclavian artery. Head-vessel debranching was performed through median sternotomy using a handmade, bifurcated, Dacron graft. Stent-grafting was performed from the ascending aorta to the proximal descending aorta. To our knowledge, this report is the first description of debranching using a custom-made graft for hybrid repair of Kommerell diverticulum.

Objective analysis of midterm outcomes of conventional and hybrid aortic arch repair by propensity-score matching

ObjectiveThe aim of this study is to evaluate the objective outcomes of conventional total aortic arch repair (CTAR) and hybrid arch repair by using propensity-score matching to reduce selection bias. MethodsBetween January 2006 and April 2016, 470 consecutive patients underwent isolated aortic arch repair (excluding hemiarch or partial arch reconstruction, and cases with concomitant cardiac surgeries) at a single cardiovascular institute. We categorized 337 total aortic arch repair with antegrade cerebral perfusion under circulatory arrest as the CTAR group and 58 hybrid aortic arch repair (HAR) with thoracic endovascular aortic repair as the HAR group. Seventy-five patients with scheduled and staged thoracic endovascular aortic repair after total aortic arch repair with elephant trunk were excluded. Then, we compared early and midterm outcomes between the propensity-matched group (43 CTAR vs HAR pairs). ResultsThere were no significant differences in 30-day and operative deaths between the CTAR and HAR groups (4.7% [2/43] vs 7.0% [3/43]; P = .4142 and 11.6% [5/43] vs 16.3% [7/43]; P = .5637). Although there were no significant differences in the incidences of other major complications, permanent stroke was observed more frequently in the HAR group (0% [0/43] vs 11.6% [5/43]; P = .0064) compared with the CTAR group. Matching analysis, however, revealed an equivalent 5-year survival rate between the CTAR and HAR groups (80.5% vs 59.9%; P = .1300). ConclusionsMatching analysis revealed a significantly greater incidence of stroke in the HAR group but equivalent midterm outcomes in the hybrid group compared with the CTAR group.

Whole body perfusion for hybrid aortic arch repair: evolution of selective regional perfusion with a modified extracorporeal circuit.

Patients undergoing hybrid aortic arch reconstruction require careful protection of vital organs. We believe that whole body perfusion with tailored dual circuitry may help to achieve optimal patient outcomes. Our circuit has evolved from a secondary circuit utilizing a cardioplegia delivery device for lower body perfusion to a dual-oxygenator circuit. This allows individually controlled regional perfusion with ease of switching from secondary to primary circuit for total body flow. The re-design allows for separate flow and temperature regulation with two oxygenators in parallel. All patients underwent a single-stage operation for simultaneous treatment of arch and descending aortic pathology via a sternotomy, using a hybrid frozen elephant trunk technique. We report six consecutive patients undergoing hybrid arch and frozen elephant trunk reconstruction using a dual-oxygenator circuit. Five patients underwent elective surgery and one was emergent. One patient had an acute dissection while three underwent concomitant procedures, including a Ross procedure and two valve-sparing root reconstructions. Three cases were redo sternotomies. The mean pump time was 358 ± 131 min, the aortic cross clamp time 243 ± 135 min, the cardioplegia volume of 33,208 ml ± 16,173, cerebral ischemia 0 min, lower body ischemia 76 ± 34 min and the average lower body perfusion time was 142 min. Two patients did not require any donor blood products. The median intensive care unit (ICU) and hospital lengths of stay (LOS) were two days and 10 days, respectively. The average peak serum lactate on CPB was 7.47 mmol/L and, at admission to the ICU, it was 3.37 mmol/L. Renal and respiratory failure developed in the salvage acute type A dissection patient. No other complications occurred in this series. Whole body perfusion as delivered through individually controlled dual-oxygenator circuitry allows maximum flexibility for hybrid aortic arch reconstruction. A modified circuit perfusion strategy may help to limit intra-operative metabolic derangements, providing improved clinical outcomes.

Orthognathic surgery for the Invisalign patient

Orthognathic surgery has continued to evolve, with increasing utilization of digital imaging and software to facilitate both the pre-surgical orthodontics via Invisalign therapy, as well as virtual surgical planning (VSP). While offering the advantage of comprehensive and patient-specific analysis, these novel technologies have also inadvertently introduced challenges in execution of the surgical plan, causing select providers to question their utility in surgical cases. Through elimination of traditional orthodontic appliances, which have historically served to provide anchoring hardware for intraoperative splint stabilization, patients managed pre-surgically with Invisalign necessitate modification of the operative techniques. Here we provide an overview of several alternative methods to facilitate maxillomandibular repositioning and stabilization, including utilization of Erich arch bars, Ivy loops, intermaxillary fixation (IMF) screws and hybrid arch bar systems. Application of these techniques in orthognathic surgery, expanded and adapted from arena of maxillofacial trauma, allows optimization of scope of indications for the Invisalign system and may increase case acceptance for surgical patients seeking esthetic and minimally invasive orthodontic options.

New Songhua River Bridge: A Continuous Girder, Tied Arch, Hybrid Bridge with Four Rail Tracks in Harbin, China

The new Songhua River Bridge, a significant project that forms part of the Harbin–Qiqihar high-speed railway line, is a continuous girder, tied hybrid arch bridge with five spans. Built as a replacement to the old bridge, the new bridge spanning the Songhua River forms a beautiful landscape with its fashionable appearance. Servicing four rail tracks, three arch ribs were used to share the train load with the continuous girder. Cast-in-place cantilever method was applied in the main girder construction, and the arch ribs were installed after the main girder had been completed. Several highlighted features of this bridge including the multiple arch ribs, variable height box girder and the hanger are discussed in this paper. Meanwhile, the unique design features such as the mechanical system, structural performance, beam-arch joint design details and the construction procedures are investigated as well. The hybrid system of continuous girder and tied arch has demonstrated its suitability for providing underneath clearance and improving the stiffness of the railway bridge.

Hybrid Techniques for Aortic Arch Aneurysm Repair.

Open repair of the aortic arch remains the gold standard for aortic aneurysms and dissections. However, in elderly patients with comorbidities, and in patients where prolonged cardiopulmonary bypass time and circulatory arrest may pose a significant risk, hybrid techniques in repairing the aortic arch have become quite attractive. Hybrid arch surgery includes a combination of endovascular and open surgery that allows surgeons to operate on the arch in a safe and expeditious manner with potential decrease in morbidity and mortality.

Short- and Long-term Results of Hybrid Arch and Proximal Descending Thoracic Aortic Repair

Purpose: To evaluate the short- and long-term outcomes of hybrid repair of the arch and proximal descending aorta in a single tertiary center for aortic disease. Methods: A retrospective analysis was performed of 55 patients (median age 67 years; 36 men) who underwent hybrid repair of thoracic aortic pathology with involvement of the arch between January 2005 and May 2015 at a single tertiary center. The pathologies included 40 (73%) with aneurysmal disease, 10 (18%) acute type B aortic dissections, 2 with acute aortic syndrome, an acute type A dissection, and left and aberrant right subclavian artery aneurysms. Seven (13%) procedures were performed as an emergency. Demographics and procedure characteristics were collected for analysis of survival and reinterventions. Results: Complete aortic debranching was performed in 14 (25%) to facilitate endograft placement in zone 0; debranching was partial in 20 (36%) patients for zone 1 deployments and 21 (38%) for zone 2. Primary technical success was achieved in 51 (93%) cases. One patient died in-hospital from aneurysm rupture following aortic debranching prior to stent-graft repair. In another, the stent-graft procedure proved infeasible and was abandoned. The other 2 technical failures were due to type Ia endoleaks. Five (9%) patients died in-hospital (4 of 48 elective and 1 of 7 emergency cases); 2 of these patients died within 30 days (4%). Eight (14%) patients had a stroke, 6 of 48 elective and 2 of the 7 emergency patients. Spinal cord ischemia was reported in 3 (6%) patients. Mean follow-up was 74.6 months. Overall cumulative survival was 70% at 1 year, 68% at 2 years, and 57% at 5 years. Reintervention to the proximal landing zone for type Ia endoleak was required in 6% of cases. The overall rate of aortic reintervention was 18% at 1 year, 21% at 2 years, and 36% at 5 years. Overall extra-anatomic graft patency was 99%. Conclusion: Hybrid repair of the aortic arch and proximal descending thoracic aorta is technically feasible, with acceptable short-term mortality. There is a low rate of proximal landing zone reintervention when hybrid techniques are used to create an adequate proximal landing zone. Extra-anatomic bypass grafts have good long-term patency. Ongoing disease progression means that further distal aortic interventions are often necessary in patients with extensive disease.

Complications at the Proximal Landing Zone of Endovascular Stent Grafts Deployed in Surgically Replaced Ascending Aorta

The ascending aorta, with its hostile angulations and forces, is the next frontier in the evolution of endovascular surgery. Type II hybrid arch repair, involving surgical replacement of the ascending aorta, arch debranching, and stent graft deployment in the ascending aortic graft, offers an opportunity to study the behavior of an endovascular prosthesis in the ascending aorta. We report complications seen at the proximal landing zone after type II hybrid arch repair. A dedicated imaging protocol was used to monitor 20 consecutive patients who underwent type II hybrid arch repair at a single center from June 2009 to July2014. Mean age was 66 years (range, 47 to 82 years). Mean imaging follow-up was 34 months (range, 12 to 64 months). There was 1 operative death (5%). Bird beaking (>5 mm of nonapposition) of the stent graft at the proximal landing zone occurred in 12 patients, and >20 mm of bird beaking occurred in 7 patients. Proximal landing zone complications occurred in 4 patients (20%), comprising 2 type Ia endoleaks, 1 graft migration, and 1 graft infolding detected on postoperative days 4, 11, 5, and 755, respectively. Three patients underwent endovascular reintervention for proximal landing zone complications. There were no late deaths. Thoracic aortic stent grafts may be prone to proximal landing zone complications when deployed in the ascending aorta. Bird beaking is common when endografts are deployed in the Dacron (DuPont, Wilmington, DE) ascending aorta. Angulation issues will likely need to be overcome by stent graft refinement to enable future closed chest approaches to the ascending aorta.

Hybrid Repair of Aortic Arch Aneurysms with Endografting of the Ascending Aorta.

Different "hybrid" techniques that combine open debranching of the supra-aortic vessels with endografting of the aortic arch have emerged as alternatives to the open arch repair in high-risk patients. This study aims to review the early and mid-term results of single-stage hybrid arch repair with ascending aorta stent graft deployment for aortic arch aneurysms and dissections. Between June 2006 and May 2015, five consecutive patients, with an age range of 54-78 years, with complex aortic arch diseases, were treated with a hybrid approach in which the endograft had a proximal landing zone in the ascending aorta. Indications included: acute and chronic type A aortic dissections and three arch aneurysms associated with distal aortic pathology. Length of postoperative clinical and imaging follow-up ranged from 10 to 121 months and was completed in all patients. Technical success of the endografting was achieved in all cases. There was one in-hospital mortality secondary to pulmonary embolism, one case of retrograde type A aortic dissection (RTAD) detected before discharge and one case of late type Ib endoleak that required an endografting procedure. No postoperative stroke or transient or permanent spinal cord ischemia occurred. Hybrid arch repair with endograft landing in zone 0 may decrease mortality and morbidity in high-risk patients. doi: 10.1111/jocs.12735 (J Card Surg 2016;31:341-347).

Repair of Late Retrograde Type A Aortic Dissection After TEVAR: Causes and Management

One of the most feared complications of thoracic endovascular aortic repair (TEVAR) and hybrid arch repair is retrograde type A aortic dissection (RTAD). More than two-thirds of RTAD occurs in the immediate postoperative period and first postoperative month. In presentations beyond that point, progression of the native aortopathy must be considered. We report a late presentation of an RTAD seven months after hybrid repair of an aortic intramural hematoma with an ulcer-like projection, and review the causes and management of this TEVAR complication.

Minimally Invasive Techniques for Total Aortic Arch Reconstruction.

The cumulative experience with endovascular aortic repair in the descending thoracic and infrarenal aorta has led to increased interest in endovascular aortic arch reconstruction. Open total arch replacement is a robust operation that can be performed with excellent results. However, it requires cardiopulmonary bypass and circulatory arrest and, therefore, may not be tolerated by all patients. Minimally invasive techniques have been considered as an alternative and include hybrid arch debranching, parallel stent graft deployment in the chimney and snorkel configurations, and complete endovascular branched reconstruction with multi-branched devices. This review discusses the evolving use of endovascular techniques in the management of aortic arch pathology and considers their relevance in an era of safe and durable open aortic arch reconstruction.

鈍的大動脈損傷に対しHybrid Arch TEVAR を施行した1 例

鈍的大動脈損傷に対しHybrid Arch TEVAR を施行した1 例

Association between Aortic Remodeling and Stent Graft-Induced New Entry in Extensive Residual Type A Dissecting Aortic Aneurysm after Hybrid Arch Repair

This study evaluated sequential aortic morphologic remodeling and influencing factors between distal stent graft-induced new entry (SINE) in chronic residual type A dissecting aortic aneurysm after extensive hybrid arch repair. We retrospectively analyzed operative and follow-up data of 30 consecutive patients with chronic residual type A aortic dissection aneurysm treated by hybrid type III arch repair (ascending aortic and arch replacement combined with elephant trunk technique before stent-graft deployment) between November 2006 and October2011. In 3 years, follow-up of 24 patients with successful 1-stage hybrid arch repair and stent grafting. The ratio of true lumen area increased at pulmonary artery level, but minimal change was seen in the thoracic segment distal to stent graft and abdominal aorta. Late distal SINE occurred in 14 patients (SINE group). Cross-sectional area showed significant differences in distal end of pre-stenting graft oversizing ratio (SINE group 4.32 vs. non-SINE group 2.23, P=0.021(∗)). The thoracic segment thrombosis rate was 90% in SINE and 57% in non-SINE (P=0.089) groups. In homogenous population of chronic residual type A dissection, noticeable false lumen thrombosis with true lumen progressive dilatation was only found at the proximal descending aortic segment extending to the middle of stent grafts in both groups. A smaller size selection of the distal stent graft by area measurement would be accompanied with poor aortic remodeling but might be beneficial for SINE prevention. On the other hand, a larger size selection of the distal stent graft area might be favorable for aortic remodeling but could potentially induce SINE.

Application of a Perfobond Rib Shear Connector Group in a Beam–Arch Hybrid Bridge

An innovative application of a perfobond rib shear connector group (PBLG) in a beam–arch hybrid bridge is introduced. Because of its excellent mechanical properties, the PBLG has been widely used in many steel–concrete composite structures around the world. However, there is currently no design code giving clear guidance regarding how to design a PBLG. The design philosophy and the reduction coefficient are two crucial aspects related to the load capacity of the PBLG. In this paper, the detailed design procedure of a steel–concrete connection using a PBLG is presented through a demonstration project. The study is considered to be of special significance to the development of new steel–concrete composite structures.

Evolving practice pattern changes and outcomes in the era of hybrid aortic arch repair

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. 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. 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. 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.

Hybrid aortic arch debranching and endovascular aneurysm repair for a thoracic aortic aneurysm impending rupture

An aortic aneurysm (AA) is an increase in diameter of at least 50% greater than expected for the same aortic segment in unaffected individuals of the same age and sex. It may be asymptomatic except when ruptured or impending rupture. When ruptured it is a life threatening emergency with a significant mortality. On presentation most thoracic AA are incidental findings found on routine work up for other causes or may present with vague back pain. We present one such case in whom a thoracic AA was incidentally detected during routine preoperative workup for squamous cell CA of the tongue. As the thoracic AA was impending rupture and the patient carried a high perioperative mortality risk with conventional aortic surgery, the patient was managed by the heart team with a hybrid technique involving an initial arch debranching surgery followed by endovascular aneurysm repair (EVAR) of the AA using three overlapping stent grafts. Keywords: aortic aneurysm; EVAR; hybrid debranching; thoracic aortic aneurysm

IMAGING EXPERIENCE OF TYPE II HYBRID AORTIC ARCH REPAIR: LESSONS LEARNT FROM 6 YEARS OF ZONE 0 LANDING AND EVOLUTION TO ZONE 2 ARCH REPAIR

Single stage hybrid aortic arch repair is a novel technique advocated for management of diffuse thoracic aortic pathology. Type II hybrid aortic repair involves surgical replacement of the ascending aorta with a Dacron graft, proximalization of arch vessels by debranching and Zone 0 stent graft deployment into the Dacron ascending aortic graft. We describe our completed experience with this technique, lessons learnt and reasons for evolution to a Zone 2 arch replacement technique. This single centre retrospective study includes 23 consecutive patients (65% male) who underwent type II hybrid arch replacement with a 4 branch Bavaria graft and Zone 0 endovascular stent graft placement, from November 2008 to July 2014. Follow up imaging was performed as per a pre-determined protocol. Imaging was reviewed by a dedicated cardiovascular radiologist to evaluate early and late outcomes and complications. Indications included aortic dissection (n=13), aortic aneurysm (n=9),and penetrating atherosclerotic ulcer (n=1), all involving the ascending aorta, arch and descending thoracic aorta. There was 1 intra-operative death. One patient was lost to follow up after 12 months. Mean imaging follow-up was 33 months (Range 4 to 72 months). One third of patients had mean follow up greater than 4.5 years. Three patients required 4 re-interventions for proximal landing zone complications -stent graft buckling (n=1), graft migration (n=1) and persistent Type 1a endoleak (n=2). There was no stent graft fracture. Proximal stent graft bird beaking within Zone 0 was seen along the lesser curve of the Dacron graft in 15 patients, 4 of which caused greater than 2 cm non-apposition. At 6 year clinical follow up there was no aortic rupture or late mortality. Perioperative and midterm survival with Hybrid Type II technique appears to be favourable. However, current generation of endografts deployed in Zone 0 have limitations in their ability to conform to the double curve of the ascending aorta, arch and descending thoracic aorta. Based on proximal landing zone complications and non-ideal apposition in the ascending aortic graft, we have moved towards extension of the surgical graft into Zone 2 of the arch with creation of an idealized Dacron landing zone for the stent graft that does not involve a double curve.View Large Image Figure ViewerDownload (PPT)

Total aortic arch replacement: A comparative study of zone 0 hybrid arch exclusion versus traditional open repair

ObjectiveWe attempted to identify predictors of adverse outcomes after traditional open and hybrid zone 0 total aortic arch replacement. MethodsWe performed multivariable analysis using 16 variables to identify predictors of adverse outcomes (mortality, permanent neurologic events, and permanent renal failure necessitating hemodialysis) in 319 consecutive patients who underwent total aortic arch replacement in the past 8.5 years and a subgroup analysis in 25 propensity-matched pairs. A total of 274 patients (85.9%) had traditional open repair, and 45 patients (14.1%) had hybrid zone 0 total arch exclusion. ResultsOperative mortality was 10.3% (n = 33): 11.1% (n = 5) in the hybrid group and 10.2% (n = 28) in the traditional group (P = .79). A total of 19 patients (5.9%) had permanent stroke (15 traditional [5.5%] vs 4 hybrid [8.9%]; P = .32), and 2 patients (both traditional) had permanent paraplegia (P = 1.00). The hybrid group had more total neurologic events (P = .051) but not more permanent strokes (P = .32). Prior cardiac disease unrelated to the aorta (P = .0033) and congestive heart failure (P = .0053) independently predicted permanent adverse outcome (operative mortality, permanent neurologic event, or permanent renal failure). Concomitant coronary artery bypass grafting independently predicted permanent stroke (P = .032), as did previous cerebrovascular disease (P = .032). In multivariable analysis, procedure type (hybrid or traditional) was not an independent predictor of stroke (P = .09). During a median follow-up of 4.5 years (95% confidence interval, 3.9-4.9), survival was 78.7%, with no intergroup difference (P = .14). ConclusionsAmong contemporary cases, both traditional and hybrid total aortic arch replacement had acceptable results. Comparing these 2 different surgical treatment options is challenging, and an individualized approach offers the best results. Permanent adverse outcome was not significantly different between the 2 groups. Procedure type is not an independent predictor of permanent stroke. Prior cardiac disease, past or current smoking, and congestive heart failure predict adverse outcomes for total aortic arch replacement.

Aortic hemiarch hybrid repair

Hybrid aortic arch reconstruction represents a treatment option for patients unsuitable for conventional open cardiovascular surgery. We analyzed patient outcome after hemiarch repair in zone 1 and zone 2 with regard to early and long-term results. Between December 2004 and December 2012, a total of 47 patients underwent hemiarch repair for distal aortic arch disease. Supra-aortic debranching was performed in 23 patients for zone 1 (carotid-carotid crossover bypass) and in 24 patients for zone 2 (carotid-subclavian bypass/subclavian transposition) followed by thoracic endovascular aortic repair. All patients included had been refused for open surgery or were emergency cases. Mean age of the patients was 65.3 years; 51% of patients were symptomatic or presented with a contained aortic rupture. Overall technical success rate was 81%, with a 30-day mortality rate of 12.8%. A primary type Ia endoleak was observed in 19%. The mean follow-up period was 50.5 months (range, 1-93 months). Follow-up mortality was 14.9%; secondary endoleak rate was 8.5% for both groups. There was a trend of reduced primary type Ia endoleak rate for zone 2 repair compared with zone 1 (4.3% vs 14.9%; P = .07). Follow-up mortality was also improved for zone 2 repair (4.3% vs 10.6%; P = .41). Overall survival rate was 70%. Hemiarch hybrid repair in high-risk patients is associated with an acceptable perioperative mortality risk and long-term survival. Zone 2 represents a feasible and effective treatment option for hybrid arch repair. Zone 1 is related with relevant risk for type Ia endoleak and higher mortality during follow-up. Lifelong surveillance after hybrid repair is essential.

Revisiting the brachiofemoral through-and-through wire technique for hybrid arch repair with a problematic elephant trunk

Revisiting the brachiofemoral through-and-through wire technique for hybrid arch repair with a problematic elephant trunk