Hybrid repair of distal arch aortic aneurysms: endovascular elephant trunk completion

Traditional open repair of distal arch aortic aneurysms requires a two-stage procedure associated with significant morbidity and mortality. The introduction of thoracic endovascular aneurysm repair has created a less invasive option to complete the second stage of the repair after proximal elephant trunk creation. The present study reports a series of patients treated with a combined open proximal and endovascular distal repair of distal arch aortic aneurysms.

A retrospective review was undertaken at a university medical center. All patients treated with the hybrid approach were identified. The patients were evaluated for demographics, preoperative imaging, technical success, postoperative complications, length of hospital stay, need for secondary intervention, and overall survival.

A total of 10 patients (3 men, mean age: 67.5 years) were identified during a 4-year period between August 2005 and July 2009. All patients were treated electively and the mean maximum aneurysm diameter was 70.8 mm. Of the 10 patients, four had undergone previous thoracotomy (three aortic repair, one pulmonary resection for malignancy) and all were deemed at prohibitive risk for open second-stage surgery. The first three patients had staged reconstruction with delayed endovascular intervention through retrograde arterial access. The more recent seven patients underwent single-stage repair with endograft delivery through an antegrade ascending aortic access. Technical success was achieved in all cases. No perioperative paraplegias or strokes were reported. One patient had successful endovascular treatment of a type IB endoleak at 38 months. Another had an enlarging thoracoabdominal aneurysm resulting in a type IB endoleak which was detected at 43 months. There was one death within 30 days after the procedure. The remaining nine patients are all alive, with a mean survival of 35.1 months (range: 8-53) after surgery.

The hybrid approach to treatment of distal arch aortic aneurysms is safe and serves as a viable alternative to conventional open repair. Less technically challenging, avoidance of a second surgery as well as elimination of the possibility of becoming lost to follow-up, or interval mortality have led us to consider a single-stage repair using an antegrade approach as the preferred option.