Short-term outcome of aortic arch repair: Debranching and thoracic endovascular aortic repair

Aim: Open repair for aortic arch pathologies remains the gold standard, despite its association with significant neurological and cardiovascular risks due to the need for cardiopulmonary bypass and deep hypothermic circulatory arrest. Hybrid techniques, combining supra-aortic trunk debranching with thoracic endovascular aortic repair (TEVAR), have emerged as promising alternatives for high-risk patients and they are still a viable alternative in face of recently intervening extremely expensive branched and fenestrated stents of total endovascular techniques in unaffordable situations. Our study aimed to evaluate the short-term outcomes of hybrid arch repair using debranching and TEVAR from our tertiary center experience prospectively.

Material and Methods: This is a prospective analytical observational study that included 60 patients who underwent supra-aortic debranching and TEVAR. Those with occlusive carotid disease, proximal landing zones of <20 mm, concomitant aortic or mitral valve replacement, or coronary artery bypass grafting were excluded. Surgical techniques included both partial and total debranching based on the Ishimaru zone classification and anatomical considerations. Primary outcomes: evaluation of post operative neurological complications like stroke and cerebral infarction. Secondary outcomes: the morbidity/mortality rate and the complications/ re-interventions’ rate, endoleak rate, intensive care unit (ICU) stay duration, Hospital length of stay and early procedural success (defined as absence of mortality, conversion to open surgery, or major complication).

Results: Of the 60 patients, 47 (78.3%) were male and 13 (21.7%) were female, with a mean age of 65.2±8.6 years. Aortic aneurysm was the most common indication (51.7%), followed by aortic dissection (31.7%) and penetrating ulcers/intramural hematoma (16.7%). The mean aortic arch diameter was 3.32±0.5 cm. Three patients (5%) had Endo leak. Six patients (10%) experienced postoperative stroke, most associated with debranching from left common carotid artery and left subclavian artery to the innominate artery (p=0.008). The 30-days mortality was 2 (3.3%), one attributed to sudden cardiac arrest on postoperative day 1 in the ICU (mostly due to development of retro A dissection and mostly ruptured), the other patient died on day 15 postoperative due to stroke complicated by chest infection and sepsis and no reported intraoperative mortality.

Conclusion: Hybrid aortic arch repair with debranching and TEVAR is safe and effective, offering acceptable early neurological outcomes and low rates of endoleak. Careful patient selection, surgical experience, and technique refinement are essential.