Hybrid repair of aortic arch dissections

Hybrid interventions combining debranching of supra-aortic branch vessels with stent grafting of the aortic arch have become an attractive alternative to open repair for aortic arch pathologies. However, results in patients with dissections of the aortic arch remain unclear. We present our experience with hybrid aortic arch repair for acute and chronic type B aortic dissections (TBAD) involving the distal part of the arch and aortic dissections distal to previous repair of the ascending aorta.

Between January 2004 and December 2011, hybrid arch repair with supra-aortic branch revascularization involving at least one carotid artery bypass and simultaneous or staged thoracic endovascular aortic repair was performed in 17 patients with a dissection involving the arch. Indications for hybrid repair were complicated acute TBAD in five patients (three impending ruptures, two malperfusion syndromes), chronic aneurysmal degeneration of a TBAD involving the aortic arch in eight, and chronic aneurysmal degeneration of a dissection distal to previous repair of the ascending aorta in four. Total arch debranching was performed in seven patients and cervical debranching in 10. Median follow-up was 13 months (range, 3-69 months).

Overall 30-day mortality and in-hospital mortality rates were 29% (5 of 17 patients). In-hospital death occurred in three of five patients (60%) with a complicated acute TBAD vs in two of 12 patients (17%) with chronic dissection (P = .12) and in one of seven (14%) with total arch debranching vs four of 10 patients (40%) with cervical debranching (P = .34). Two (12%) fatal strokes and four (24%) retrograde aortic dissections occurred. Retrograde aortic dissections tended to be more prevalent in patients with acute TBAD than in those with chronic dissection (3 of 5 vs 1 of 12; P = .053). No spinal cord ischemia was recorded. Two other patients died, at 8 and 26 months, after the operation of causes not related to the aortic dissection. Persistent perfusion in the aortic false lumen of the graft exclusion segment was identified in six patients, due to type III endoleak (n = 2) requiring additional endovascular intervention, type II endoleak (n = 3), or retrograde perfusion from distal fenestrations (n = 2). No proximal type I endoleak was identified. During follow-up, the dissected aorta distal to the stent graft remained stable in all surviving patients.

In this series, mortality rates and incidence of retrograde aortic dissection were significant after hybrid repair of aortic arch dissections, especially in acute cases. These results are in contrast with previously published series including other aortic arch pathologies. They suggest that dissections of the aortic arch may represent a less favorable patient cohort.