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Hybrid and Endovascular Management of Complex Aortic Arch and Descending Thoracic Aortic Pathology
Vasilios D. Kollias, Vasilios Lozos, Dimitrios Angouras, John Toumpoulis, Christos Rokkas.
University Hospital of Athens "Attikon", Athens, Greece.

OBJECTIVE: To assess the feasibility and safety of hybrid and endovascular techniques in the treatment of complex diseases of the aortic arch (AA) and the descending thoracic aorta (DTA) in patients at high surgical risk.
METHODS: We retrospectively studied all high risk patients with complex AA and DTA pathology who received endovascular or hybrid therapies without the use of cardiopulmonary bypass over the past 2 years.
RESULTS: Nine patients, aged 70.7 ± 13 years, having a logistic Euroscore of 19.9 ± 6.9 were included. The patients were divided in two groups, according to aortic pathology: AA±DTA aneurysm (4 patients-group A) and proximal DTA penetrating atherosclerotic ulcer or intramural hematoma (5 patients - group B). In group A patients a “hybrid” repair was implemented, with off-pump surgical debranching and revascularization of the aortic arch vessels and concomitant endovascular deployment of stented endografts reaching into the ascending aorta, in a single stage (figure: BG bifurcated graft, CA celiac artery, AAA aortic arch aneurysm, DTAA descending thoracic aorta aneurysm). In 3 of 4 patients a left carotid-subclavian bypass was also performed. Patients in group B were treated solely by endovascular placement of stented endografts. In 4 of 5 patients the left subclavian artery was excluded. In one of these patients a carotid-subclavian bypass was required in a second stage. Complications included one type I endoleak in group A and one type V local dissection of distal ascending aorta in group B. One patient (group A) died postoperatively due to low cardiac output syndrome.
CONCLUSIONS: Off-pump hybrid and endovascular techniques can be successfully used in the management of high surgical risk patients with complex disorders of the aortic arch and the descending thoracic aorta. New grafts designed to conform to the anatomy of the aortic arch are being developed.

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