Hybrid (Open And Endo) Treatment Of Aortic Arch Aneurysms And Dissections

Background Despite technical and technological improvements, open repair of aortic arch pathologies is still associated with high mortality and morbidity rates, mainly related to deep hypothermic circulatory arrest and cerebral ischemia. Patients ineligible for traditional open surgery might benefit from a hybrid approach, consisting of aortic arch debranching with rerouting of the supra-aortic trunks and endograft exclusion of the pathological portion of the aortic arch. We report our experience with aortic arch aneurysm hybrid repair. Patients and Methods Between 1998 and 2012, 465 patients underwent TEVAR for thoracic aortic pathologies in our Center. Among this group, 151 patients with aortic arch aneurysm were categorized according to the Ishimaru classification and treated by means of hybrid repair. Most of these patients had been refused by cardiac surgeons as considered “high-risk” for severe comorbidities. For zone 0, the operation was performed through median sternotomy. The ascending aorta was side-clamped and a “Y” graft was tailored for the making of an ascending aorta-innominate artery-left common carotid artery bypass. For zone 1, a carotid-to-carotid or a carotid-to-carotid-to-left subclavian bypass was performed through bilateral cervical access. The absolute indications for left subclavian artery (LSA) revascularization in zones 0 and 1 aneurysms at our Institution were (1) coronary circulation supplied by the LSA through the left internal mammary, (2) inadequate contralateral vertebral artery, (3) young patients, (4) left-handed professionals, and (5) high risk for spinal cord ischemia. For zone 2 patients treated early in our experience, the LSA was revascularized only in selected cases; in our more recent cases, LSA revascularization has been performed routinely, reserving coverage without revascularization to urgent cases. After the surgical stage a commercially available endograft was deployed in the pathological portion of the aortic arch. The preferred timing of procedure was simultaneous. Patients were evaluated in follow-up with chest radiography and contrast CT scans at 1, 6, and 12 months and yearly thereafter. Angiograms were obtained in selected cases (i.e., endoleaks). Clinical follow-up was also performed at regular 6-month intervals. Results One hundred twenty-five atherosclerotic and 26 dissecting aneurysms, were categorized according to Ishimaru’s classification as 35 zones 0, 37 zones 1, and 79 zones 2. Thirty-day mortality in zone 0 was 11.4% (n=4) due to intraoperative stroke in 3 cases and retrograde dissection in 1. Thirty-day mortality was 2.7% (n=1) and 2.5% (n=2) in zone 1 and 2, respectively. The overall rate of type I endoleak was 7.3%. Two zone 2 patients (2.5%) developed spinal cord ischemia. At follow-up (mean 24.5±18 months) two patients treated for zone 1 aneurysm died because of aneurysm rupture. Three patients died for unrelated events. Four cases of acute retrograde type A dissection were observed during follow-up: 3 cases were successfully treated with ascending aorta and arch open repair under hypothermic circulatory arrest, one patient died for ascending aortic rupture before the scheduled operation. Conclusions In selected patients with arch disease, early and midterm outcomes of hybrid repair are promising although mortality, especially in zone 0, is still significant and the risk of retrograde dissection has to be assessed. These results may have practical implications for the ongoing evolution of the hybrid repair as well as for patients fit for traditional surgery.