Hybrid arch surgery challenges other forms of arch treatment

Abstract

Introduction: The gold standard for aortic arch replacement remains total arch replacement (TAR) procedure. Hybrid techniques, utilizing a combination of open and endovascular approaches, have been developed with goal of lowering postoperative mortality and morbidity, as well as providing an alternative therapy for patients who are elderly, have significant comorbid burden, or patients in whom circulatory arrest may pose significant risk.

Evidence acquisition: To date, there are no prospective randomized trials comparing hybrid aortic ach procedures to TAR. Further, many case series describing the outcomes of hybrid procedures involve cohorts with significant comorbidities and, thus, comparison with historical, total arch replacement controls is difficult. However, retrospective studies comparing hybrid arch procedures to TAR are accruing including a Society of Thoracic Surgery Database review conducted by our institution.

Evidence synthesis: Review of the literature demonstrates that the optimal surgical management of aortic arch pathology remains a clinical challenge. Several institutions, including our own, have demonstrated that hybrid arch procedures can be safely performed with acceptable postoperative outcomes and improvements in aortic remodeling. However, many other groups have advocated for the use of hybrid procedures only in the setting of high risk patients due to concerns for increased risk as compared to total arch replacement. At present, the majority of the available data suggests that hybrid arch procedures are most frequently reserved for patients who are of significant operative risk.

Conclusions: Hybrid arch procedures are frequently employed for high risk patients. The available data demonstrates that in this population these procedures produce satisfactory outcomes.