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 Hybrid | Zone 2 Hybrid | TEVAR Only | p-value | ||||
| N | 40 | 20 | 56 | ||||
| Perioperative Mortality | 6 | 15% | 2 | 10% | 6 | 11% | 0.78 |
| Any Complication | 31 | 78% | 10 | 50% | 14 | 25% | <0.001 |
| Stroke | 12 | 30% | 1 | 5% | 4 | 7% | 0.003 |
| Vocal Cord Paralysis | 7 | 18% | 0 | 0% | 1 | 2% | 0.005 |
| Bleeding | 10 | 25% | 2 | 10% | 3 | 5% | 0.017 |
| Cardiac Complication | 16 | 40% | 5 | 25% | 6 | 11% | 0.004 |
| Spinal Cord Ischemia | 5 | 13% | 3 | 15% | 2 | 4% | 0.16 |
| Paralysis at Discharge | 2 | 5% | 3 | 15% | 0 | 0% | 0.017 |
| AKI/ARF | 11 | 28% | 3 | 15% | 7 | 13% | 0.16 |
| Dialysis | 1 | 3% | 2 | 10% | 2 | 4% | 0.37 |
| Pulmonary Complication | 13 | 33% | 6 | 30% | 9 | 16% | 0.14 |
| GI Ischemia | 1 | 3% | 1 | 5% | 3 | 5% | 0.78 |
| Wound Complication | 1 | 3% | 2 | 10% | 0 | 0% | 0.054 |
| Discharge Home | 18 | 45% | 13 | 65% | 42 | 75% | 0.011 |
