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

Abstract

Objective 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. Methods 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. Results 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. Conclusions 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.

Long-term survival and related outcomes for hybrid versus traditional arch repair—a meta-analysis

“…The literature search identified 1,268 records, of which nine satisfied the inclusion criteria and definitions for hybrid versus traditional aortic arch surgery (6,7,(18)(19)(20)(28)(29)(30)(31) (study details in Table S1). Two studies were identified as high quality, three as intermediate quality and four as standard quality using the adapted scoring criteria.…”

“…studies used as basis for exclusion (6,(18)(19)(20). Given the differing baseline patient characteristics of Sun's study, pooled Kaplan-Meier analysis excluding these results was conducted, showing better long-term survival and reduced death rate for conventional repair than hybrid repair ( Figure S2).…”

“…Attenuation of overall effect due to broad definitions was evident when examining particular meta-analytic outcomes for our included studies. For example, for early mortality, those hybrid cohorts with a large (or total) proportion of debranch procedures (6,7,18,19) had RRs closer to unity than for hybrid cohorts consisting of predominantly FET patients (28,30,31). Differences in intra-operative factors such as usage of cardiopulmonary bypass usage for hybrid procedures (7) or concomitant procedures potentially also lead to heterogeneity.…”

“…The inside fold is then everted and anastomosed with the proximal aorta-the distal end of the graft is left free-floating in the descending aorta to be secured during a second-stage procedure (10,16,17). If the second stage involves securing the trunk via endovascular intervention, then the procedure is considered to be a hybrid repair (rather than traditional repair) (10,18,19 Areas of the aorta affected by pathology and targeted as landing-zones for endovascular stents were defined according to the zone definitions established by Mitchell, Ishimaru and colleagues (22). Hybrid arch repair was classified according to definitions used by Bavaria and colleagues (3): hybrid type I repair: aortic arch vessels are de-branched and re-implanted on the healthy native proximal aorta, with a subsequent endovascular stent graft then placed to cover the diseased aorta; hybrid type II repair: the proximal ascending aorta is resected and replaced by a prosthetic graft, followed by arch vessel de-branching and re-implantation on the prosthetic graft, and completed by an endovascular stent inserted to cover the distal portion of the diseased aorta; hybrid type III repair: a socalled 'frozen' or stented elephant trunk is deployed during conventional arch replacement to facilitate concomitant aortic arch and proximal descending aneurysmal repair in a single stage.…”

Isolated ascending aorta endografting: Another brush for the aortic reconstruction artist

“…Endovascular arch procedures using branched or fenestrated endografts or open arch debranching have proven feasible, but remain technically challenging and anatomically treacherous due to a reliance on ascending aorta proximal landing zone (Ishimaru zone 0) 1 with the attendant risks of device migration, coronary or arch vessel occlusion, and retrograde dissection. 2 However, a more restrained application of proximal aorta endografting that avoids the technical challenges of arch vessel preservation entails isolated pavement of the supracoronary ascending aorta, from the sinotubular junction to the innominate artery, for select high-risk patients with focal aortic pathology contained wholly within this segment. However, this short arc of aorta is poorly accessible by standard percutaneous routes and no devices are specially designed for the unique length, diameter, and curvature specifications of the ascending aorta.…”