Endovascular Stenting With Open Surgery for Reconstructions of the Ascending Aorta and the Aortic Arch: A Review of Indications and Results of Hybrid Techniques

Abstract

Hybrid approaches for repair of aneurysms involving the ascending aorta and the aortic arch have been developed to avoid or reduce duration of cardiopulmonary bypass and circulatory arrest and to decrease operative time, blood loss, hospital stay, morbidity, and mortality. These include ascending aorta-based debranching or cervical extra-anatomical bypasses followed by stent-grafting. In patients with associated descending aortic aneurysms, the elephant trunk technique is used followed by stent-grafting of the descending thoracic aorta. A review of the literature of hybrid aortic arch reconstructions, published over past 7 years, reveals perioperative mortalities from 0% to 13%, stroke from 0% to 10%, and spinal cord injury in 0% to 13%. The outcomes are comparable to contemporary results from total open and total endovascular reconstructions in spite of the fact that the hybrid approach is generally taken in patients with high surgical risk for open repair and with prohibitive anatomy for total endovascular repair.

Techniques and Results of Aortic Arch Hybrid Repair

“…Stroke and spinal cord injury were reported in 2 % and 1.5 % of the patients, respectively. The total endoleak frequency was of 6 % [10].…”

Combined surgical and catheter‐based treatment of extensive thoracic aortic aneurysm and aortic valve stenosis

“…In this case, the decision was made to surgically “de‐branch” the aortic arch by constructing a large Y‐shaped Dacron® prosthesis at the level of the ascending aorta—instead of surgical bypass grafting the supra‐aortic vessels one‐by‐one . The subsequent TEVAR procedure was challenging due to a short “landing zone” in the ascending aortic prosthesis, but by placing the stiff guide wire in the left ventricle, the deployment of the endovascular stent graft was very controllable and the proximal end of the stent graft ended precisely in the pre‐destined “landing zone.”…”

Untitled

“…(512,513) La gran ventaja de las técnicas híbridas es que evitan someter al paciente a circulación extracorpórea, hipotermia profunda, parada circulatoria y protección cerebral. (514,515) Finalmente, las decisiones para tratar las enfermedades del arco aórtico deben ser hechas por un "Aortic Team". Sería conveniente, en caso de tratamientos electivos, que sean realizados en centros especializados en cirugía abierta, vascular y endovascular (Recomendación Clase I, Nivel de evidencia C).…”