HYBRID AORTIC ARCH SURGERY TO CREATE A LANDING ZONE IN THE ASCENDING AORTA

Thoracic Endovascular Aortic Repair (TEVAR) has enabled the treatment of aortic pathology that previously required open surgery, with higher morbidity and mortality. The need for a favorable landing zone (Lz), without compromising the patency of the supra-aortic vessels meant that Ishimaru Lz 2 was the most proximal technically feasible Lz. We developed a hybrid technique for the creation of a more proximal Lz in high risk patients - in the first stage, debranching/ rerouting of the supra-aortic vessels, with or without ascending aorta replacement, was performed; a few weeks later, a TEVAR with a LZ in the distal ascending aorta was performed. This technique allowed the avoidance of the more aggressive total arch and proximal descending aorta replacement (Elephant Trunk or Frozen Elephant Trunk - FET) in high risk patients. We reviewed all patients who underwent hybrid arch surgery in our Department to create a more proximal Lz that allowed safe TEVAR stent placement. From November 2007 to October 2019, 15 patients required hybrid surgery to achieve treatment - 9 by replacing the ascending aorta and debranching supra-aortic vessels and 6 by debranching and re-routing supra-aortic vessels to the native ascending aorta. All underwent computed tomography angiography within 30 days of surgery and had follow-up with annual appointments and imaging control. Patients average age was 65.5 (+/- 11.5) years, 73.3% being male. Average follow-up was 54.7 (+/- 46.2) months. The most common diagnosis was thoracic aortic aneurysm (66.7%), followed by chronic type B aortic dissection (20.0%), pen- etrating atherosclerotic ulcer (6.7%) and reintervention due to endoleak (EL, 6.7%). No in-hospital mortality was registered. ICU and hospital stay was 1.3 (0.8) days and 9.8 (10.3) days, respectively. Survival at 1- and 5- years was 84.6% and 65.8%, respectively. No EL was detected in 66.7% (n=10) of patients. Incidence of early EL was 20.0% (n=3), of which two-thirds had spontaneous resolution, and late EL was 13.3% (n=2). Endovascular reintervention was required in one patient. TEVAR in the context of hybrid surgery is associated with low morbidity and mortality, with a low incidence of EL and good early and long term survival.