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Have Hybrid Procedures Replaced Open Aortic Arch Reconstruction in High Risk Patients: A Comparative Study of Open Arch Debranching with Endovascular Stent Graft Placement and Conventional Open Total and Distal Aortic Arch Reconstruction
Rita K. Milewski, Wilson Y. Szeto, Alberto Pochettino, G William Moser, Patrick Moeller, Joseph E. Bavaria; Hospital of the University of Pennsylvania, Philadelphia, PA
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Objective: Open total arch (OTA) and open distal arch plus proximal descending aortic (ODAD) procedures can be performed electively with adjunct circulatory and cerebral perfusion management. These procedures have been associated with significant, even prohibitive, morbidity and mortality in patients with multiple comorbidities. Open aortic arch debranching with endovascular stent graft placement as a single stage procedure has emerged as a surgical option in this patient population. This study evaluates the outcomes of a contemporary comparative series from one institution of open total arch, open total arch plus descending aorta, and hybrid surgical procedures for extensive aortic arch pathology.
Methods: From July 2000 to September 2008, 1196 open arch procedures were performed: 694 elective hemiarch, 49 OTA, 42 ODAD and 350 emergent hemiarch and open descending procedures. From 2005 to 2008, 61 open (hybrid) endovascular procedures were performed: 37 emergent Type A dissections and 24 elective open arch debranchings.
Results: Primary outcome measures of Mortality, Transient Neurological Deficit (TND), and Permanent Neurological Deficit (PND) were evaluated. Univariate analysis revealed age >75years(y) as a predictor of mortality (p<.06) in the open aortic repair group. For patients >75y, mortality for elective hybrid was 9.09% (1/11), elective OTA 40% (4/10), and elective ODAD 20% (1/5). For patients <75y, mortality for elective hybrid was 15.38% (2/13), elective OTA 9.38% (3/32), and elective ODAD 0%. TND in elective ODAD was 3.0% (1/32) for <75years(y) and 20% (1/5) for >75y. TND in elective OTA was 12.5% (4/32) <75y and 10.0% (1/10) >75y. TND in the elective hybrid was 7.69% (1/13) <75y and 18.18% (2/11) >75y. PND in elective ODAD was 3% (1/32) <75y and 0% >75y. PND in elective OTA was 9.38% (3/32) <75y and 10% (1/10) >75y. PND in elective hybrid was 15.38% (2/13)<75y and 18.18%(2/11) >75y. Multivariate analysis did not demonstrate a difference in either TND or PND between procedure groups.
Conclusion: Hybrid arch debranching with endovascular stent graft placement provides a safe alternative to open repair. This study suggests that arch repair using the hybrid approach has a lower mortality for high risk patients greater than 75 years old. This extends the indication for a hybrid arch approach to patients with complex aortic arch pathology who were previously considered prohibitively high risk for conventional open total arch repair.

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