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Hybrid Management of Aortic Arch Pathology: An Institutional Experience
Andrew Sanders, MD, Sai Yadavalli, MD, Jorge Gomez-Mayorga, MD, Sabrina Straus, BS, Lars Stangenberg, MD PhD, Mark Wyers, MD, Allen Hamdan, MD, David Liu, MD, Marc Schermerhorn, MD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.

Objectives: Management of arch pathology remains a complex arena within vascular surgery. Various open techniques exist but are accompanied by significant morbidity and mortality, especially in high-risk patients. Total endovascular management is often unable to fully address the degree of disease without sacrificing important vasculature. As such, hybrid techniques (using concurrent open/endovascular procedures) are often employed in this region. Here, we present our experience with such techniques.Methods: We conducted a retrospective analysis of hybrid arch procedures at a single institution, including hybrid cases where the open/endovascular components were performed in a staged manner during separate admissions, from 2007-2022. Additionally, we studied TEVARs that involved a component of the arch without an open element. Aneurysm, PAU, dissection, and trauma patients were included. Cases were stratified as zone-0/1 hybrid, zone-2 hybrid, and arch-TEVAR. We evaluated perioperative outcomes with χ2 analysis and long-term outcomes using Kaplan-Meier methods.Results: We identified 40 zone-0/1 hybrid, 20 zone-2 hybrid, and 56 arch-TEVAR patients. While there was no statistical difference in perioperative mortality (15% zone-0/1 vs 10% zone-2 vs 11% arch-TEVAR,p=.78), zone-0/1 cases were more likely to experience a perioperative complication and less likely to be discharged home (78% vs 50% vs 25%,p<.001; 45% vs 65% vs 75%,p=.01, respectively) (Table). Stroke and vocal cord paralysis were two such complications that occurred significantly more frequently in zone-0/1 cases (30% vs 5% vs 7%,p=.01; 18% vs 0% vs 2%,p=.01). Zone-0/1 cases had higher mortality at four years and reintervention at three years but these did not reach significance (33% vs 10% vs 21%,p=.13; 45% vs 33% vs 22%,p=.13, respectively). There were two instances of rupture, both in the arch-TEVAR cohort.Conclusions: Our institutional experience revealed zone-0/1 hybrid cases to have the most associated morbidity and higher rates of perioperative mortality. Zone-0/1 cases were also associated with higher long-term mortality and reintervention. We suspect that larger cohorts are needed to confirm the significance of the differences which we observed. Even despite a hybrid approach, proximal arch surgery remains a high-risk procedure. Improvements in patient selection and custom devices are necessary to improve patient outcomes.
Table 1. Perioperative Outcomes

Zone 0 or 1 HybridZone 2 HybridTEVAR Onlyp-value
Perioperative Mortality615%210%611%0.78
Any Complication3178%1050%1425%<0.001
Vocal Cord Paralysis718%00%12%0.005
Cardiac Complication1640%525%611%0.004
Spinal Cord Ischemia513%315%24%0.16
Paralysis at Discharge25%315%00%0.017
Pulmonary Complication1333%630%916%0.14
GI Ischemia13%15%35%0.78
Wound Complication13%210%00%0.054
Discharge Home1845%1365%4275%0.011

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