Can Hybrid Aortic Arch Repair Surpass Total Arch Replacement?
Tomohiro Mizuno, Tatsuki Fujiwara, Kiyotoshi Oishi, Masashi Takeshita, Masafumi Yashima, Eiki Nagaoka, Keiji Oi, Hirokuni Arai.
Tokyo Medical and Dental University, Tokyo, Japan.
Objective: Less invasive hybrid arch procedures have not spread yet because of relatively high rates of neurological and aortic complications. We have utilized a one-staged hybrid arch and descending thoracic aortic repair (HAR) for seven years with elaboration of surgical procedures since 2012. Methods: Total arch replacement (TAR) was the first priority only for arch disease, and HAR was for extended thoracic descending aortic disease including aortic arch. Both procedures were performed only via median sternotomy. In HAR, Zone 0 thoracic endovascular aortic repair (TEVAR) was concomitantly performed under stable circulation with a systolic blood pressure higher than 120mmHg in one stage after the ascending aorta and partial or arch was replaced with reconstruction of three arch vessels and cardiopulmonary bypass (CPB) was weaned off (Figure). In 5 cases, the ascending aorta was preserved. We assessed the outcomes of the HAR procedures (55 patients) and compared them to those of the total arch replacement (TAR) procedures (75 patients). Results. In HAR, no operative mortalities or permanent neurological deficits were observed. The mean height of the distal end of the stent grafts (SG) in HAR was located at Th8.6 (Th7-11), and the rate of spinal cord injury was 1.9%. Although operation time in HAR was longer than that of TAR due to concomitant TEVAR procedure, CPB time, aortic cross-clamp time, and lower body ischemic time in HAR were significantly shorter than those in TAR (p < 0.01). Postoperative respiratory-support time tended to be shorter in HAR than in TAR. The rate of seven-year freedom from all-cause death in HAR (81.1%) were statistically similar to that in TAR (82.6%), but the rate of seven-year freedom from surgery- and SG-related complications in HAR (83.0%) was lower than that of TAR (95%) due to SG-related complications including SG-induced aortic dissection (p < 0.01). Conclusion: Our one-stage HAR can treat wider range of aortic disease than TAR and provides excellent long-term outcomes similar to that of TAR. However, only for arch disease, HAR is acceptable for patients who require less invasive surgery, but HAR cannot surpass TAR until further improvement of SG therapy. 
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